Inspection on 24/10/07 for Holme Lodge Care Home

This inspection was carried out on 24th October 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 7 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 24/05/07

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 Joanna Carrington Unannounced Inspection 24th October 2007 10:00 Holme Lodge Care Home DS0000008697.V351124.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.V351124.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.V351124.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) Manager post vacant Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Holme Lodge Care Home DS0000008697.V351124.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 24th May 2007 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.V351124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit, as part of the home’s key inspection took place on 24th October 2007. This was the home’s second key inspection within six months. 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 residents were selected and their care was tracked through discussion with them and with staff, checking their care records and observing practice. Altogether four residents and four 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 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. At the time of writing this report a survey from a relative and a survey from a healthcare professional had been returned. Services are now required to fill in a document called an AQAA (Annual Quality Assurance Assessment) in which the registered manager identifies from their own quality monitoring what the service does well at and what they need to improve on. The AQAA was also returned before the site visit and was used to plan the site visit and to support judgements made in this report. What the service does well: There is a robust admissions procedure, which ensures prospective residents that the home will be suitable in meeting their needs. Residents are involved in writing care plans and instructing staff on how they want their support. The service does well at supporting residents to maintain relationships with their family and friends. Specialist health care professionals such as occupational therapists, speech and language therapists and district nurses are involved in residents care when this is necessary, which ensures that residents’ healthcare needs are met. Residents and relatives feel comfortable passing on their concerns and complaints and are confident that these are taken seriously and acted on. allegations of abuse are followed up using the local Nottinghamshire procedures, which is important for the protection of all residents. All The staff team are well trained and new staff members have a comprehensive induction, which includes the principles of care and all mandatory training so that care is provided safely to residents. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 6 There are good systems in place for the monitoring of the quality of care and also on seeking the views of service users. There are regular house meetings and other forms of consultation. There is a Service User Support Group; they visit the home to talk with residents and to listen to their views. What has improved since the last inspection? What they could do better: Due to a number of permanent vacancies at the home some of these beds are being used for short breaks. This provision needs to be included in the Statement of Purpose so that people know short breaks are part of the service. Although staffing numbers have improved at the home there is not enough permanent staff. This means that a lot of agency / temporary staff are being used, which is raised as a concern by residents, staff and a relative. Residents do not like having their personal care needs met by people they do not know. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 7 Catering arrangements are not adequate. The cook is working on her own to cook meals and keep the kitchen clean. The quality of meals is suffering because of this. When residents want to have some involvement in managing their health and medication this should be included in their care plan. Where it is decided that the staff team still take overall responsibility in this there should be a risk assessment carried out, to identify why this is measure is necessary and how the individuals’ independence can be promoted safely. There is no audit trail for stocks of medication in the home. This means that it cannot be checked that residents are being given their medicines as prescribed. Staff members must not commence employment until the return of two written references. This is to protect residents from people that maybe unsuitable to work with vulnerable adults. The gas and central heating system has not been serviced, which does not promote and protect the health and safety of residents. 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.V351124.R01.S.doc Version 5.2 Page 8 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.V351124.R01.S.doc Version 5.2 Page 9 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 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust admission procedures mean that prospective residents are assured their diverse needs will be met. Significant progress with updating information for prospective residents means they will be able to make an informed decision about moving to the home. EVIDENCE: The pre-admission assessment was seen for a resident that is currently at the home on a short break. The care supervisor reported that she and a senior carer travelled to London to visit the prospective resident in order to carry out the assessment. The assessment shows that this resident’s short break has been planned very thoroughly in order to ensure his needs around his ethnicity and culture are met. Care plans have been developed from this information and close attention to gender, personal care routines and dietary requirements, particularly in the light of the resident’s religion are clearly stated in the care plans. The cook, when spoken with demonstrated a good level of understanding and awareness of the resident’s dietary needs, and this was prior to the resident’s arrival at the home. Since the last inspection the acting manager has been working on the Statement of Purpose and Service User Guide by updating the information. The Service User Guide also uses pictures alongside written information, to Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 10 make the information accessible to more people. This work is not yet completed. The number and size of rooms is not yet included in the Statement of Purpose. There are currently two residents in the home that are there on a short break and the manager reported that there has been a lot of interest in short break stays. This is not yet included in the Statement of Purpose or Service User Guide. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. Care planning arrangements are improving greatly, which now assures residents their needs will be met and their right to take risks and make choices upheld. EVIDENCE: The care supervisor has been working on developing a new system for care plans and residents spoken with confirmed that they have been involved in this process, deciding on what is written in care plans and what is included on the files. There was evidence of this on the new files with residents’ signatures. For those case tracked residents that this process how now been completed the care plans are much more user friendly, with information easy to find, and evidence to indicate that the care plans are reviewed with the resident. A case tracked resident is currently in the process of devising a communication book with the Leonard Cheshire Communication Officer. The resident is meeting with the officer weekly, selecting pictures and magazines that she Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 12 wants to use in the communication book. A staff member explained that this has made the exercise far more meaningful for the resident. There is a care plan stating the service user’s communication needs, which stresses how the resident makes her own choices. House meeting minutes show that service users are involving in decision making in the home, with regards to the décor and maintenance, activities and menu planning. There are also opportunities for residents to be involved in the recruitment of new staff and to be part of regional and national Leonard Cheshire service user forums. There is a Service User Support Team, which is made up of residents from other Leonard Cheshire services that visit and provide support and help people to have a voice. For the three case tracked residents there were risk assessments on their files, which cover activities of daily living as well as individuals’ chosen activities and interests. A resident that has recently had a speech and language assessment for swallowing difficulties has a risk assessment for choking, with measures such as soft foods and thicker fluids, as recommended by the speech and language therapist. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Significant improvements are being made in this area, which means residents’ rights are safeguarded and residents are being supported to have fulfilling lives that meet their personal expectations and goals. Catering arrangements are not good enough to ensure residents enjoy their meals and mealtimes. EVIDENCE: Some residents were at day centre or at college at the start of the inspection. Residents at home explained that it was their choice not to go to arranged day services but preferred to either spend time doing craft work in the home or to relax watching television. One resident has keyboards in his bedroom, which he enjoys playing. Another resident talked about his weekly visits to the gym. The care plans seen show that residents are being consulted over their main interests and goals. The disabled supporters club for Notts Forest football team have met a resident at the home in order to arrange for him to meet a supporter at matches. A staff member will accompany him until he is confident Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 14 to do this independently. Some residents recently went to goose fair with staff. A resident has recently been supported to take a taxi independently to go visit his sister and another resident regularly goes to see his family for tea. A resident spoken with said his brother regularly visits and is always made welcome by the staff team. Since the last inspection there has been a lot of attention spent on the issue of privacy and dignity. The staff team have had a workshop in which case studies and scenarios were looked at and talked about. Staff spoken with had very positive comments to make about the day and how valuable it was to talk about the issues and how ensure these values are embedded into their practice. Residents spoken with said staff are “very kind” and treat them with dignity and respect. This was observed. There were mixed responses about the quality of meals. A resident said that it depends on who is the cook for that day and that some of the meals are not very warm. The menu records show that there are always two choices for the main meal, and a variety of nutritious balance meals, with alternative puddings provided for people with diabetes. Arrangements for meal times are not adequate as the kitchen is down to one permanent cook and no other assistants, on some days cooks are being brought in via an agency. It is not possible for one cook to provide all meals as well as maintain satisfactory standards of hygiene in the kitchen. The cook was seen to be under a lot of pressure. The cook, when asked, commented that she feels quality of meals are suffering because of this. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 15 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. The health and personal care needs of residents are being met but medicine management is not effective enough in ensuring medicines can be tracked and that they are being given to residents as prescribed. EVIDENCE: All residents spoken with reported they are happy with the assistance they get with their personal care; they confirmed they can get up, go to bed and can have a bath or shower when they wish. The care plans seen for personal care were very detailed and contain individuals’ preferences. For example, “I have long hair which I like to have brushed daily and placed in a variety of styles”. Dignity is covered in detail also on care plans, with reference to gender preferences, and how choices and privacy must be respected at all times. This is written as directed by the resident. Daily records and care plans indicate that relevant healthcare professionals such as psychiatrist, speech and language therapists and district nurses are Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 16 involved in residents’ healthcare when necessary. A healthcare professional confirms that the healthcare needs of residents are always met and that the staff team always ask for support where required. Key workers have been reviewing service users’ care by making sure they are up to date with healthcare checks including visits to the dentist and opticians etc. A case tracked resident that has diabetes has a support plan for the control of his diabetes but it does not include enough information about dietary control. The resident explained how he takes his own blood sugar tests and records them in his own book. Being involved in this way appeared very important to the resident, but was not reflected in the care plan, it just said that the senior carer does this. The care supervisor explained that the senior carer also records this in the care plan. There is no risk assessment for selfadministration, to explain why the service user cannot manage his diabetes independently. The notes from a recent Boots Advisory Visit were seen, which confirmed there were no concerns identified from this visit about medicine management. The storage of medicines is well organised and medication administration records had clear instructions for administration that tallied with labels. The medicines in monitored dosage systems that were checked had all been given correctly. For boxed medicines any tablets remaining from a previous cycle are not being carried forward onto the current cycle, which means there is no audit trail to make sure residents are being given their medicines as prescribed and no way of tracking stocks. This was picked up as an issue at the last inspection. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 17 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. Residents are assured that their concerns, complaints and allegations are taken seriously and acted on. EVIDENCE: All residents 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. A relative commented in their survey, “any complaints made… are taken very seriously”. There has been one complaint made since the last inspection and records of this complaint show that appropriate action was taken and that the residents concerned were formally notified of the outcomes. 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. There has been one safeguarding adults referral made since the last inspection, which was concerning a resident allegedly assaulting another resident. This was notified at the time and procedures were followed accordingly for the safety and protection of all residents. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 18 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 adequate This judgement has been made using available evidence including a visit to this service. Improvements to the environment made since the last inspection means residents now have comfortable, more homely surroundings to live in. EVIDENCE: A relative points out in their survey that “the buildings are old and need updating”. The building itself and layout are not suitable in moving the service forward in line with best practice provision for disabled people. The facilities in the home are not conducive to promoting residents’ independence. For example, the tea-making area is not wheelchair accessible and meals and mealtimes are by an industrial-sized kitchen. This is why the service is going to be re-provisioned. In the meantime, from touring the premises it is evident that since the last inspection there has been some work to the premises in order to freshen the décor and environment. The communal areas of the home have been re-painted and residents spoken with confirmed they were involved in choosing colour schemes and new Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 19 furniture. A resident spoken with was very happy with her newly decorated bedroom. All bedrooms seen were personalised with individuals’ own items and furnishings and decorated to suit their personal taste. On the day of the inspection areas of the premises seen, including bathrooms were clean and hygienic. Laundry facilities are appropriate to the needs of residents. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 20 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, 33, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing arrangements are improving in that residents’ needs are met by appropriate numbers of staff and also by the continuing high standard of training provided. Not having enough permanent staff members, however does compromise this. Residents are at risk of being supported by unsuitable staff if not all checks are carried out before they start their employment. EVIDENCE: Both staff members and residents spoken with confirmed that staffing numbers have improved at the home. Shifts are not being run below safe numbers. It was reported that following the reorganisation of staffing a number of staff members left the service, which has resulted in there not being enough permanent staff to cover all the support. A resident spoken with expressed his dissatisfaction with this because he does not always know who is providing his care. A relative commented in their survey that the home could improve by “employing their own staff” which “gives the residents a high level of security”. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 21 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. A new staff member talked about her block induction and the mandatory training she did as part of this induction. The new staff member demonstrated they understand the principles of care, disability issues and importance of health and safety. The file of the new staff member was examined and found to contain evidence of a criminal record bureau check prior to the staff member commenced their employment. Both written references were dated just after the new staff member commenced their employment. A requirement in respect of references was made at the key inspection in April 2006. The new manager did show evidence that written references had already been obtained for a new staff member whose start date was in the next few weeks. There was evidence on the staff member’s file that they have had supervision to discuss progress in the role and any developmental needs. Staff spoken with said that the manager was very supportive. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. There are now suitable management arrangements in place, which means improvements to the service are being seen, that are in the best interests of residents. The overdue servicing of the gas system means that residents’ health and safety is not promoted or protected. EVIDENCE: A new manager was recruited to the home in July 2007. The manager is in process of applying for registration. The manager confirmed that she has had good support from her line manager with settling into the position and identifying priorities for action. Both residents and staff had very positive comments to make about the new manager, describing her as being ‘supportive’ and getting on with things. The Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 23 staff team showed respect for the manager because she has spent time on the ‘shop floor’ observing practice and getting involved. Records were seen in the form of house meeting minutes and also of one to one time spent with residents asking them about the quality of care and what things can be improved. This exercise is being undertaken with the service user support team as the manager feels in hindsight individuals may have not felt comfortable being honest with a new manager. The annual selfassessment for Leonard Cheshire is due in November and a full service audit next year. The fire log indicates that all fire alarm testing is now being undertaken and certain staff members have been assigned this task when the designated person is on leave. The Annual Quality Assurance Assessment stated that hoists were last serviced in February 2007. The manager reported that these have been serviced again in August, within the required six months but records of this could not be located during the inspection. At the time of the inspection the servicing of the gas and central heating system was overdue because the contractor will not service the system until a new extractor system is installed in accordance with new regulations. Since the inspection action has been taken to begin addressing this problem. A contractor has agreed to service the central heating system and Leonard Cheshire have agreed funding for new extractor system. Environmental Health department are fully aware of situation. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 3 3 X 4 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 1 X Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 25 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 YA17 Regulation 16(2)(i) Requirement There must be appropriate catering arrangements in place, for the preparation and serving of meals or to enable service users to prepare their meals themselves. Care plans must reflect the support given to assist someone to control their diabetes. This is to ensure health is maintained and also to empower individuals to have some control of their own care. Risk assessments for the selfadministration of medication must be carried out for service users that want to have some control / level of involvement in taking their medication. This is in order to consider ways to promote residents’ independence. There must be an audit trail for all medicines received into the home. This is so that all medicines can be tracked and to ensure residents are given their DS0000008697.V351124.R01.S.doc Timescale for action 01/12/07 2 YA19 15(1) 24/01/08 3 YA20 13(2) 01/12/07 4 YA20 13(2) 01/12/07 Holme Lodge Care Home Version 5.2 Page 26 medication as prescribed. 5 YA33 18(1)(b) There must be enough 24/01/08 permanent staff employed at the home so that the use of temporary staff is to a minimum and does not adversely affect the continuity of care for service users. New staff members must not commence employment until the return of two satisfactory written references. This is to help ensure service users are protected from people unsuitable to work with vulnerable adults. Appropriate action must be taken so that the gas and central heating system comply with health and safety legislation and so that it can be serviced. This is to ensure the health and safety of service users. 01/12/07 6 YA34 19(1)(b) 7 YA42 13(4)(c) 01/12/07 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 Refer to Standard YA1 Good Practice Recommendations Include in the Statement of Purpose the arrangements for short breaks / respite care. This is so that people know this provision is offered in the home. Holme Lodge Care Home DS0000008697.V351124.R01.S.doc Version 5.2 Page 27 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. 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