CARE HOME ADULTS 18-65
Holme Lodge Care Home 1 Julian Road West Bridgford Nottingham NG2 5AQ Lead Inspector
Joanna Carrington Key Unannounced Inspection 26th April 2006 10:00 Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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.V292419.R01.S.doc Version 5.1 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.V292419.R01.S.doc Version 5.1 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.allenshaw@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) Joanne Louise Ollerenshaw Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users shall be within category PD Date of last inspection 15th November 2005 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 ensuite. 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 amenties of West Bridgford and the city centre are only a short bus ride away. The fees at the home are based on a pricing and costing tool, which means they are set based on individuals’ needs. Currently, fees range from a minimum of £600 to a maximum of £947.85 per week. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over eight hours on 26th April 2006. This was the home’s key inspection for this inspection / financial year. The main method of inspection was called case tracking which meant selecting three residents and tracking the care and support they receive through talking with them, talking with staff and observation of care practices. Two of the residents that were case tracked were spoken with along with three other residents and four members of staff. The manager was available for discussion and feedback throughout. Judgements made in inspection reports are now not only based on what is found during the day but also from evidence accumulated over the year, since the previous inspection. What the service does well: What has improved since the last inspection?
The content of care plans has improved and been updated which means that staff have enough information to meet the current needs of individuals in a consistent and safe manner. There is now a care plan in place for a named resident that will sometimes refuse their medication. Staff now have guidance on what they should when this happens. Meeting the healthcare needs of residents is now being done much better, by monitoring their weight and having detailed care plans on how to prevent and treat pressure sores. The medication system is now much safer because instructions for the administration of medicines are clearer All information held about residents is now stored securely. This is important for respecting and protecting confidentiality.
Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 6 There is an excellent system for monitoring quality at the home, including an improved Service User Satisfaction Survey, which covers various aspects of the service. At this inspection staff were observed treating residents with dignity respecting their right to privacy whereas at the last two inspections two different staff were observed walking into bedrooms without knocking. There is now a system in place for formal supervision sessions for staff. This is an essential element of staff support, particularly important for a staff team that has suffered low morale. Some new staff have now been recruited, which has subsequently had a positive impact on the morale of staff. Residents should benefit from this as the staff team will be able to carry out their role more effectively. What they could do better:
All residents must have a community care assessment, which is available. This is very important as this information acts as a baseline for identifying when needs have changed, and also regarding issues of funding with placing authorities. These could not be traced during the inspection. Residents still require risk assessments, with the relevant care plans in order to promote their safety and independence. This is now outstanding from two previous inspections therefore an immediate requirement has been issued in respect of this. There is still not enough detail on menu records that reflect was meals residents have been served. This detail is important for evidencing that meals are varied, balanced and nutritious and that there is choice. This is an outstanding requirement from the previous inspection. For purposes of food hygiene and protecting the health of residents fridge and freezer temperatures must be recorded daily. This is also outstanding from the previous inspection. Residents do not have sufficient access to the community, which then has a detrimental impact on their quality of life and right to social inclusion. In the light of this issue mainly, staffing levels need to be reviewed. For a named resident that has ‘when required’ medication when they become distressed a care plan must be devised so that there is guidance to staff on when it is appropriate for this medication to be given. There are still plans for the home to be re-provisioned but in the meantime there are parts of the home that would benefit from a lick of paint so that the environment is welcoming and comfortable for residents. It is acknowledged that the temporary manager in post has made improvements to the service. However, now that there is no longer a registered manager in post, the manager is now required to be registered with the Commission. Recruitment practice needs to be more robust by ensuring that two written references are obtained for staff before they commence employment. This is for the protection of residents. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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.V292419.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality for this outcome area is poor It cannot be ascertained that the needs of residents are assessed before they are admitted to the home because the assessments could not be traced. EVIDENCE: At previous inspections the placing authority’s community care assessments and pre-admission assessments have been seen on the files of residents case tracked. However, at this inspection assessments were not on the residents’ files and could not be located either. It is required that this assessment is retained by the home for all residents, as this information provides a baseline for implementing care plans, for identifying when needs have increased and for reassessment. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Quality for this outcome group is adequate. Some significant progress has been made with the content and reviewing of care plans, important for ensuring the current needs of residents are being met. Residents are supported to make decisions about their lives, but to ensure that individuals’ independence and safety is promoted the necessary work to risk assessments is still outstanding. Information held about residents is now being handled appropriately, which means their confidences are kept. EVIDENCE: For the four residents case tracked their care plans showed that these have been updated and now provide detailed information on how to meet the health, personal care and social needs of residents. The care plans continue to be written in first person which supports the fact that resident’s own their respective care plan and the information in it. Not all of the care plans are dated, which is important for purposes of reviewing and tracing when an individual’s needs have changed. Residents can keep their care plan in their rooms, which was observed and residents spoken with confirmed that they have been involved in its development, which is evidenced as the care plans are signed.
Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 11 There are still no risk assessments accompanying care plans. These are required not only for typical issues of health and safety that apply to all residents but also for activities of daily living and interests specific to individuals. This is so that residents’ quality of life and independence can be promoted within an appropriate risk management framework. The care plans seen show that residents are supported in accessing independent advocacy services and it is documented when residents are helped with managing their finances and who is providing this help. There is also information available to staff on how to communicate with certain residents, where this is an identified need. At the last inspection the complaints file was found to contain documents and correspondence concerning residents of a very sensitive nature. This file at the time was not being held securely. This is no longer the case. The file has been filtered and all information is now held confidentially. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality for this outcome area is adequate. Although contact with family and friends is promoted overall the social and recreational needs of residents are not being adequately met. Residents are offered a healthy diet and enjoy their mealtimes. Residents’ rights are being respected and upheld. EVIDENCE: From looking at the visitors book and discussion with residents it is evident that residents can have visitors when they want and that families and friends are welcome. All residents spoken with stated that staff always knock on their bedroom door and await permission before entering. A member of staff was observed assisting a resident with eating, being mindful of the resident’s choices and maintaining their dignity and respect. Staff spoken with demonstrated an understanding of important values when providing personal care and support. This is a real improvement compared to the last two inspections. Residents were observed eating and enjoying their meal and all residents spoken with described the meals as “good” or “nice”. The menu plans show a
Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 13 variety of healthy meals are offered and at lunchtime the cook told residents the two options of lamb chops and meatballs. Both meals looked very appetising. Menu records still need to be more detailed as only writing “potatoes and veg” each day could mean that the same thing is always provided. There was a boat trip that some residents went on last week but unless something is arranged way in advance, on a day-to-day basis staffing levels do not allow for residents to access the community and to use public amenities. All residents spoken with wished that they could get out more and this was an issue that all staff spoken with also identified. Residents said that unless they are attending college or participating in the craft group at the home on other days when they have no organised activities they feel “bored”, which was sensed during the inspection. One resident that has been living at the home said that in the whole time they have lived there, which is in excess of a year, they have only got out to the local pub with staff once. Staff spoken with said are happy to work extra hours but these are for covering shifts therefore there is very little opportunity for key workers to take residents shopping or to assist residents in following their hobbies and interests. This is set as a requirement. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality for this outcome group is good. Residents receive personal support in the way they prefer and require and there have been improvements to record keeping which assures that healthcare needs are met. Further progress has been made with the medication system, which now means that procedures are now at an acceptable safe standard. EVIDENCE: The updated care plans now provide more detail on how personal support is to be given including individuals’ preferences for example, with when they like to get up, whether they prefer a bath or shower and how much assistance is needed with dressing etc. There are forms identifying gender preference and also consent forms that residents sign in relation to the sharing of sensitive information about their care needs. There are records for when residents have had chiropody appointments, and seen GPs, district nurses and for when other specialist healthcare professionals have been accessed such as dieticians, community psychiatrists and physiotherapists. It seems from discussion with residents and looking at records that these appointments are rarely attended in the community but professionals visit the home, which is a rather institutional approach to accessing healthcare. It is recommended that this be looked into.
Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 15 The requirement set at the last inspection to maintain in respect of each resident a record of pressure sores and treatment provided by staff has now been met. There are care plans in place and turning charts although staff must ensure that they are filled in everyday otherwise they are of no use. For the four residents case tracked they are all having their weight monitored according to their current health and individual needs. This requirement from the previous inspection has therefore now been addressed. The requirement to document in a care plan any action to be taken when a named resident refuses their medication has now been met. For this particular resident it was noted in a behaviour chart that they had been given a behaviour modifying “as required” medication. This is a form of restraint. A care plan must be developed providing guidance to staff on how to respond to this behaviour and at what stage “as required” is given and ensuring that a second staff member is consulted and signs following administration. This is for the protection of the resident from any unnecessary or unethical restraint. Instructions on medication administration records (MAR) are now much clearer although it is recommended as a precautionary measure that photocopies of prescriptions be attached to MAR records to ensure the pharmacy has dispensed medicines in accordance with prescriptions rather than with previous MARs. There was one error in which the note section on the MAR had not been filled in therefore not providing enough information as to why this medicine is not being given. This does not promote safe practice. Overall, nevertheless, the system for storage, administration and recording is much improved. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality for this outcome area is good. There is an appropriate complaints procedure in place that assures residents their concerns are taken seriously and acted on. Staff are aware of the Nottinghamshire Adult Protection Policy and Procedures and of their responsibilities in protecting residents from abuse. EVIDENCE: Since the last inspection the Commission received a complaint made by a relative on behalf of their resident in care. This complaint was passed back to the provider for them to investigate and respond to. This complaint was responded to immediately and in fact the issue concerned had already been resolved by the time the Complaint was received. A record of this complaint and action taken has been made in accordance with their Complaints Procedure and is held on the Complaints file. No other complaints have been made since the last inspection but the complaints file does demonstrate that residents concerns are listened to and acted on. Residents spoken with confirmed that they know how to complain and who to complain to. In accordance with the Nottinghamshire Committee for Protection of Vulnerable Adults Policy and Procedures the Commission have received a copy of the outcome form that is sent to the Adult Protection Unit following an adult abuse investigation. There have been no other allegations / disclosures of abuse since the last inspection. Staff spoken with did demonstrate an understanding of the Protection of Vulnerable Adults Procedures and their responsibilities in respect to disclosing allegations of abuse and whistleblowing. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality for this outcome area is adequate. Residents’ live in a clean environment, but despite some attention to residents’ bedrooms and also to the provision of specialist equipment, the décor throughout the home is in need of attention, prior to the planned reprovisioning of the home. EVIDENCE: There has been no planned refurbishment or redecoration at the care home due to the planned re-provisioning of the service to a new site. Land has still not been located for the re-provisioning so ideas of using the current site are being discussed. The manager has made some progress on redecorating bedrooms that most needed it and a track-ceiling hoist has been installed along with a new shower. In the meantime, however, in some parts paint is crumbling or has come off walls but mainly the paintwork and general décor of the home is looking very outdated and in need of freshening up. This would make the environment more cheery and comfortable for residents. This is set as a requirement. The requirement to carry out the re-provisioning of the home remains in this report. On a partial tour of the premises it was evident that the home is kept clean and hygienic. There are adequate sluicing facilities and there is a good-sized laundry room, sited away from where food is stored or prepared.
Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality for this outcome area is adequate. The training needs of staff are met and progress is being made with the provision of formal support to staff, which residents will ultimately benefit from. Recruitment practices do not protect residents unless all of the necessary preemployment checks are carried out. Progress with the recruitment of staff has helped improve morale and subsequently, meeting the needs of residents however, the number of staff available on some shifts is not sufficient in ensuring that the needs of residents are met. EVIDENCE: Four staff files were looked at. Although for all four staff the required Criminal Record checks had been undertaken two of these staff that have been recruited since the last inspection, only had one written reference on their files when there should be two. Supervision sessions are now taking place for staff. Supervision records were seen on the staff files looked at. A system for supervision has been implemented, with senior staff being trained to give supervision sessions. For a staff team that has suffered low morale it is important that supervision is seen as a regular thing.
Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 19 Low morale has been partly due to the team being very short-staffed. All staff spoken with at this inspection commented on how this situation is improving. Some new care staff have been recruited as well as a housekeeper and maintenance person. A new Care Supervisor is still to be appointed, that deputises for the manager. The duty rota showed that shifts are usually run with either three of four staff. It is questionable that three staff is an adequate number given the layout of the home, the mobility and care needs of residents and limited community access (refer to Standard 13 for further evidence) therefore staffing levels need to be reviewed. This is set as a requirement. 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 Whistleblowing. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality for this outcome area is good. There are excellent systems for monitoring quality at the home that includes seeking the views of residents. The leadership, guidance and direction to staff have meant there has been significant improvements to the service, which has helped to ensure the health, safety and welfare of residents is promoted and protected although better recording in the kitchen is still required. EVIDENCE: Since the last inspection the home has had its quality audit by the provider Leonard Cheshire. This audit took place over the course of one week and was very through covering all aspects of the service. The audit report was seen and shows how comprehensive an audit this was and has identified action required. At the last inspection it was pointed out how the Service User Satisfaction Survey was not adequate because it only asked one general question. Since then, a much better survey has been produced that asks residents a series of questions about the quality of care including involvement in their care plans, choice of food and respecting privacy.
Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 21 All staff spoken with praised the temporary manager for all of the improvements they have seen to the service and described her as being approachable, supportive and effective. The hard work of the temporary manager is acknowledged however, now that the registered manager will not be returning to her post, which should at time of confirmation been notified to the Commission, the manager must now apply to be registered with the Commission. Given that the current acting manager was only brought in on a temporary basis, and has no intentions to stay on permanently, to ensure stability and to maintain improvements at the service the Provider must consider appointing a permanent manager for registration. The servicing of equipment and electrical and gas systems are all up to date which is important for promoting the health and safety of both residents and staff. There are now risk assessments for bed rails being undertaken following a requirement made at a previous Leonard Cheshire’s Health and Safety Audit. The requirement set at the last inspection to ensure all required fire safety testing is undertaken has now been addressed. Fridge and freezer temperatures are not being recorded daily, which is now an outstanding requirement from the previous inspection. This practice is necessary for ensuring food is stored at a safe temperature to avoid food poisoning and illness. Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 22 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 X 2 1 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 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 4 X X 2 X Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement Ensure all residents are assessed prior to being admitted to the home and that a copy of the assessment is retained in the home and available for inspection. Ensure that activities in which service users participate in are free from avoidable risks and that there are risk management strategies / assessments attached to care plans that are reviewed. (This is an outstanding requirement from the previous two inspections, original timescale 30/09/05 not met. Therefore an immediate requirement has been issued.) Enable service users to be a part of the local community and to engage in local, social and community activities. Timescale for action 31/05/06 2. YA9 13, 14 26/04/06 3. YA13 16 31/08/06 Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 24 4. YA17 16 5. YA20 13, 15 6. YA24 23 7. 8. YA24 YA33 23 18 9. 10 11. YA34 YA37 YA42 19 8 12 In accordance with Schedule 4 (13) ensure that a record of food provided for each service user is in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. This is an outstanding requirement from previous inspection, timescale 30/11/05 not met. Devise a care plan for the named resident that is administered behaviour modifying “as required” medication. This is to ensure that this medication is administered as a last resort. Carry out intention to reprovision the physical environment over the next 3-5 years. Ensure the premises are reasonably decorated throughout. Review staffing levels to ensure that, having regard to the size of the care home, statement of purpose and number and needs of service users, it is at a safe level and appropriate for their health and welfare. Ensure two written references are obtained before a person commences their employment. The manager must apply for registration with the Commission. Ensure for protecting the health of service users that fridge and freezer temeratures are recorded daily as a necessary measure for the prevention of food poisoning and illness. This is an outstanding requirement, initial timescale 30/11/05 not met. 31/05/06 30/11/05 01/04/07 31/08/06 30/07/06 31/05/06 31/07/06 30/11/05 Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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 YA13 Good Practice Recommendations Review with residents their expectations and wishes regarding activities and support accessing the community. This is repeated from the last inspection. Remind residents of their right to have a key to their room, and if declined then record in care plan. This is repeated from the last inspection. Photocopy prescriptions and attach to MARs before they are handed over to the pharmacy. This will help in auditing drugs and ensuring administration instructions tally with any changes. 2. YA16 3. YA20 Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holme Lodge Care Home DS0000008697.V292419.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
