Inspection on 20/05/09 for Holme Manor Care Home

This inspection was carried out on 20th May 2009.

CQC found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Holme Manor Care Home Holme Manor Holme Lane Townsend Fold Rossendale Lancashire BB4 6JB Lead Inspector Mrs Christine Mulcahy Key Unannounced Inspection 20th May 2009 02:03 DS0000072883.V376676.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holme Manor Care Home Address Holme Manor Holme Lane Townsend Fold Rossendale Lancashire BB4 6JB 01706 218953 01706 830735 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) Mr Ryan John Godwin Mrs Fallon Natalie Ann Godwin Manager post vacant Care Home 32 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (32) of places Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP DE - Code DE The maximum number of people who can be accommodated is: 32 Date of last inspection Brief Description of the Service: Holme Manor Residential Care Home is registered with the Commission for Social Care Inspection to provide 24 hour care and accommodation to 30 older people who have dementia and 2 older people. The home is situated in the Rossendale valley within easy access of the M62 and M66 Motorway network. The building is stone built and in its own grounds. The home has 30 single bedrooms and 1 companion room on two levels which can be accessed via a passenger lift or stair lift. There is a nurse call system, laundry facilities and most rooms have adjoining en suites. There are a number of shared toilets and bathrooms near to bedrooms and communal areas. Facilities for private telephones are available and all bedrooms have lockable storage space. Communal rooms are furnished to a comfortable standard and decorated to suit the varied tastes of the residents. The conservatory extends the popular sitting area in the entrance hall. The fees charged are determined through a thorough needs assessment and can be discussed with the registered manager. Residents pay for personal effects like toiletries, clothing and hairdressing. Copies of the homes service user guide and statement of purpose are given to prospective residents and their families. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service received a key (main) inspection on 21/05/09. Before the inspection took place the manager was asked to complete a document called an Annual Quality Assurance Assessment (AQAA). This document provides information on the services strengths and weaknesses and any future plans to develop the service. Surveys were also made available to people living at the home and staff to find out their views. Other information since the last inspection was also reviewed. As part of the key visit we used a system called case tracking. This is a method that allows us to follow or track a particular situation so we can be sure it was dealt with appropriately. Since the last key visit the Commission has received notification from the Local Authority about two safeguarding incidents that have occurred at the home. The quality rating for this service is zero star. This means the people who use the service experience poor quality outcomes. What the service does well: Residents at the home could move freely around the home and could use their bedrooms at any time. Daily routines were structured but flexible enough to meet the needs and preferences of people using the service. 29 care staff are trained in NVQ Level 2 & 3 in care. What has improved since the last inspection? What they could do better: Written information about the care home should be up to date and accurate so that prospective residents can make an informed choice about living at the home. Written information in care plans must be up to date, reviewed regularly and reflect the individual resident. This means that staff would know what to do to meet resident’s needs fully. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 6 Policies and procedures for handling Controlled Drugs must be followed to prevent mis administration and risk of harm to residents. Attention to Health and safety policies and procedures relating to hygiene in the home must be followed to ensure residents live in a safe, clean and hygienic home. Routines of daily living and activities must be made available and flexible to suit resident’s expectations, preferences, and capacities so that resident’s find the lifestyle at the home satisfies their social cultural, religious and recreational interests and needs. The homes complaints procedure must be made available to residents and their representatives so they know that their complaints will be listened to, acted on and taken seriously. Attention to the homes staff recruitment policy and procedure must be made to ensure that all pre employment checks are done and residents are safeguarded from the risk of abuse or harm from staff through lack of training, ignorance and negligence. Resident’s rights and best interests must be safeguarded by the homes record keeping policies and procedures to ensure the effective and efficient running of the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 1, 3 & 6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admission and assessment procedures are in place to help meet the needs of people using the service but written information about the home is out of date and misleading. EVIDENCE: People moving into Holme Manor receive a copy of the home’s statement of purpose. The document tells people about the home and the facilities available but still contains information relating to the previous owner and the previous staff team skills and qualifications. The document was last reviewed in 2006 and does not provide an update about the new owner and new registered manager. This means that residents or prospective residents cannot make an informed choice about moving to Holme Manor because information contained in the statement of purpose is out of date and misleading. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 9 Records kept of four people who live at Holme Manor were examined and these records held a copy of the needs assessment that had been completed before they moved into the home. Signed copies of their service agreement and contract were also seen in the records. Intermediate care is not provided at this home. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 7, 8, 9 & 10 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans were not detailed enough for staff to know how to fully meet the resident’s needs. The system for compliance with Controlled Drugs was not being followed and lack of adequate recording might put people using the service at risk of harm from medicine mis management. EVIDENCE: We examined four resident’s care plans and noted that people using the service have access to healthcare services like GP and District Nurses. Two residents were being supported by the nurse practitioner following discharge from hospital. All residents were able to retain their own GP and there was good written evidence that residents could access local services if they needed like dentist, optician and specialist healthcare appointments. Aids and equipment needed and recommended by health care professionals like falls mattress, pressure relieving cushions and mattresses, commodes, Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 11 hoists and wheelchairs were in good working order and seen in use around the home to support and meet the changing needs of people who lived there. There was evidence in care plans of health care treatments, interventions and general health care information but some of the details were inaccurate and one of the care plans stated that a resident was continent of urine and feceas. On meeting the resident it was apparent they were not. This means that the presence of inaccurate information on the care plan prevented the care staff from fully meet resident’s needs. Two care plans did not include a falls risk assessments for residents who needed a falls mattress at the side of their bed. This means that if one of the residents fell out of bed it could not be shown how the care staff monitored or recorded the incident because the risks were not highlighted. Risk assessments that should have focused on the residents daily routines and behaviour were not in place therefore new risks had not been identified and residents actions were not fully safeguarded. Care plans seen included a needs checklist that listed information about the resident’s physical health, personal hygiene needs their likes and dislikes, their finances and where the resident needed support in their daily living. However these records were sparse and didn’t give a full picture of the resident. Important health information like catheter care and tissue viability was only held on the district nurse care plan and not the resident’s daily care plan. This means that care staff didn’t have enough information about the resident to be able to make full and accurate observations about them to fully meet their care needs. Staff were observed treating resident’s kindly and with respect throughout the visit. The registered manager confirmed that medical examinations and treatments were always done in the resident’s own room. A medication policy and procedure was shown us and contained a summary of what staff should do when handling medication. A comprehensive medication training manual was also shown to us but it was unclear why a copy of this document was not available in the medication cabinet for staff to refer to. Daily medicines were stored safely and securely in a locked cabinet. Records relating to residents daily medication were examined and seen to be up to date and accurate. Controlled Drugs (CD) were stored securely and only designated staff had access to both types of medicines. There was no clear system for compliance with the receipt, recording, handling and administration of Controlled Drugs in the home. Examination of the Controlled Drugs Register showed that administration and receipt of the medication had not been recorded properly. Three Buprenophine patches for one resident were counted but the CD register had a record of there being only one patch left. A new box of patches was delivered on 16/05/09 but a dedicated page in the CD register was not available. Another resident’s Midazolam injection was recorded in the CD register but it could not be shown who this medication belonged to and administration records were unsigned by staff. The registered manager was not aware of the gaps in the CD register. This means that staff will be unclear of what is required and the current practice when administering Controlled Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 12 Drugs. This means the system for compliance with the administration, safekeeping and recording of Controlled Drugs was not being followed and lack of adequate recording puts people using the service at risk. Currently 13 care staff are trained to administer medicines to the residents. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Leisure and recreational activities at the home were limited which means that people do not have opportunities to participate in stimulating and meaningful activities. The menu provided choice and variety and was enjoyed by the residents. EVIDENCE: There was little evidence to show that regular activities had been planned for residents although diary dates had been confirmed for the hairdresser to visit fortnightly. A member of the Clergy last visited on the 10th May but there were no dates diaried for future visits. Newspapers bought daily were available to resident’s who were able to read them. Throughout the key visit residents were observed sitting in the communal lounge areas with little or no stimulation to occupy them. A television was on for most of the day in the main lounge but many of the residents did not watch it. It was apparent that meal times were used by care staff to socialise with Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 14 residents but this interaction was brief as staff needed to get on with their work. Visitors and relatives were seen in the home throughout the key visit. Five residents each in a wheelchair were observed sitting around an unset dining table for up to 20 minuets before their lunch was served. The resident’s were approached by care staff after we highlighted to the registered manager the lack of stimulation for these people. The meals served at the home were of good quality, well presented and met the dietary needs of the people using the service. Care staff are trained to help those people who need help when eating and were observed doing this in a sensitive manner. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 16 &18 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service were not protected by the safeguarding procedures and these were not fully understood by managers and staff. EVIDENCE: There is a complaints and safeguarding procedure that is clearly written and easy to understand. The complaints procedure specifies the timescales and stages for the process. There is a robust policy and procedure for safeguarding adults giving clear guidance to the staff. All staff received abuse training as part of their mandatory induction. The manager was unaware of the need to ensure that all residents and their representatives are provided with an up to date copy of the complaints procedure. The manager could not show us a complaints book used to record immediate concerns or complaints and copies of the complaints procedure was not widely available in the home. When asked care staff were aware of the safeguarding procedure and one care staff said that she would inform the manager if she suspected abuse to residents. Two recent safeguarding concerns made to CQC by the professional agencies highlight the lack of management knowledge about safeguarding referrals to Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 16 relevant agencies. The concerns have also highlighted incidents that have been poorly managed with issues not always satisfactorily resolved. People living at the home have been at risk of harm from other residents and there is a lack of staff knowledge around restraint and diffusing difficult situations. This means that people using the service are not fully protected by the care homes safeguarding procedures and are at risk of harm because of this. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 19 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service live in an environment that provides specialist equipment to maximise their independence. Some areas of the home were not clean or hygienic enough to ensure the residents comfort. EVIDENCE: A tour of the home showed that it provides a physical environment that meets the specific needs of the people who live there. The home is comfortable and residents can personalise their own room. All bedroom doors have are lockable and residents can have a key to their room if they want. En suite facilities are available in most rooms and these are shared with an adjoining bedroom. Toilets and bathrooms are appropriately located within the Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 18 home and are easily accessible in sufficient numbers. Some of the en suite facilities were malodorous and required a thorough clean. Communal areas were clean and tidy but two bedrooms needed immediate deep cleaning to the carpets. New mattresses and new washable floor coverings were also required. Another bedroom needed the patio door lock replacing to make the room secure from intruders and prevent the resident leaving the home unnoticed. A used dishwasher that was blocking the patio doors to the outside of the bedroom was removed after we reminded the manager of the need to maintain a clear escape route in an emergency. The manager was cooperative and ensured all of these areas were addressed immediately with minimal or no disruption to the residents who used those rooms. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures for the recruitment of staff need to be more thorough to ensure suitable staff are employed to safeguard people using the service EVIDENCE: The staff rota showed there was enough staff on duty during the day and at busy times to meet the specific needs of the residents’. There were enough night staff on duty and the managers were always available if they were needed in an emergency. We observed care staff involved in the daily tasks and routines of the home, meeting the resident’s needs in a professional and sensitive manner. A copy of the training matrix was examined and showed staff training was ongoing. Out of 30 care staff 19 are trained to NVQ Level 2 & 3 in care. 3 are trained in 1st Aid, 9 have been trained in moving and handling and 20 are currently undertaking training in dementia care. 13 care staff are trained in the safe handling of medication, and 6 staff have received training in diabetes. The manager said that safeguarding training, moving and handling and food hygiene are covered as part of the homes mandatory induction training. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 20 There is a robust recruitment procedure in place for the manager to follow when recruiting new staff and this helps to ensure the protection of people using the service. Examination of 4 staff files showed that pre employment checks were done but the CRB for 2 staff was not available for us to examine. This means that it could not be shown that pre employment checks had been done properly and the homes recruitment procedure ensure residents were fully safeguarded from abuse and the risk of harm. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 31, 33, 35, 36 & 38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current management systems do not ensure the efficient and effective running of the service and the ongoing service improvements. EVIDENCE: The new management team has been in place since October 2008 and only the registered manager is qualified to run the home. There is an expectation from the registered provider that the manager will spend a few hours a week running the domiciliary home care service, which is also owned by the registered provider, alongside the running of the care home. This means that the registered manager cannot ensure that the needs of the people using the Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 22 service are being fully met because she isn’t fully aware of what is happening in the care home. Supervision of staff at the home is inconsistent and staff lack leadership. The manager does not understand strategic planning and review. Policies and procedures are up to date but not shared amongst the staff team and quality assurance monitoring is not done. This means that the manager does not recognise policies and procedures, service reviews and quality to be core management tools. Other professionals have raised their concerns to us about the lack of robust management systems and it is apparent that some residents have been placed at risk because of this. The Annual Quality Assurance Assessment (AQAA) was returned to us on time but the content of the document was brief and gave very little information about the service and there is minimal evidence to support any of the claims made within it. There is a lack of understanding of the purpose of the AQAA because the document showed that all questions relating to residents wellbeing were poorly completed and areas of the AQAA are repeated throughout the document and does not give a reliable picture of the service. The registered provide disclosed that neither he nor the registered manager completed the AQAA and neither of them proof read it before it was sent to us. The registered manager and provider were unaware of the homes philosophy and ethos and both were unable to discuss the expected outcomes for the residents. There was no focus on equality and diversity or promoting human rights and care plans were only person centred in parts. We have been advised about a number of incidents that placed residents and staff at risk because staff have not had sufficient training to enable them to work more safely under these circumstances. The registered manager did not notify us about any of these incidents and was unaware that we needed to be informed. The resident’s and relatives and representatives manage the resident’s money and the home keeps small amounts of cash for those residents whose relatives have asked for this to be done. Checks to ensure residents money was handled properly was done. Staff, residents and relatives signatures verified the transactions. Checks showed that records are generally up to date although some gaps were found in recording and entries were not always clear. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 15 3 X X X X X X 1 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X 3 2 2 1 Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation Schedule 1 Timescale for action The statement of purpose must 05/10/09 include the name and address of the registered provider and manager, relevant staff qualifications, and staff experience, the organizational structure of the care home and who it is intended the accommodation is for. 05/10/09 The registered person must prepare a written plan after consultation with each resident or their representative. The plan must show how the residents health and welfare needs will be met. Individual care plans must be drawn up with the involvement of the resident and show how the care is to be delivered taking into account their wishes and preferences. The registered person shall 21/05/09 make arrangements for the recording, handling safe keeping, safe administration and disposal of medicines received into the care home. Receipt, administration and DS0000072883.V376676.R01.S.doc Version 5.2 Page 25 Requirement 2 OP7 Reg 15 (1) 3 OP9 Reg 13(2) Holme Manor Care Home 4 OP12 Reg 12 (4) disposal of Controlled drugs are recorded in a Controlled Drugs Register to prevent the risk of mis management. The registered person must 05/10/09 make suitable arrangements to ensure that the care home is conducted with due regard to the sex, religious persuasion, racial origin and cultural and linguistic background and any disability of residents. Particular consideration must be given to people with dementia and other cognitive impairments and they are given opportunities for stimulation through leisure and recreational activities in and outside of the home which suits their needs preferences and capacities through a planned and written schedule of activities. A record of all complaints made by residents and their representatives or by people working in the care home about the operation of the care home and the action taken by the manager in respect of such a complaint should be kept. The registered person must make arrangements by training staff or other measures to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that no resident is subject to physical restraint and if this is used it must be the only practicable means of securing the welfare of the resident. The DS0000072883.V376676.R01.S.doc 5 OP16 Schedule 4. (11) 20/05/09 6 OP18 Reg 13 (6, 7, 8) 05/10/09 Holme Manor Care Home Version 5.2 Page 26 registered person must record the circumstances including the nature of the restraint. 7 OP26 Regulation The registered manager must 13 (4) keep the care home free from 16(2) (k) offensive odours and ensure that all parts of the home that resident have access to are so far as reasonably practicable free from hazards to their safety . Regulation To ensure that residents are 19 fully protected from abuse or risk of harm the registered manager must operate a thorough recruitment procedure and obtain an up to date CRB for the person intending to work at the home. Schedule 4 Regulation 17 (2) 4 The registered manager must ensure that records required by regulation for the protection of residents and the effective efficient running of the service is maintained, up to date and accurate. The registered person must maintain in the home records specified in schedule 4. 21/05/09 8 OP29 21/05/09 9 OP37 05/10/09 10 OP38 Regulation The registered manager must 12(1) (a) ensure that so far as 13 (2) reasonably practicable the health, safety and welfare of residents and staff is promoted and protected. 21/05/09 Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 27 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 OP9 Good Practice Recommendations A copy of the homes medication training manual should be kept in Controlled Drugs cupboard and on medicines trolley so that care staff are reminded of the system for compliance with the administration of Controlled Drugs. Holme Manor Care Home DS0000072883.V376676.R01.S.doc Version 5.2 Page 28 Care Quality Commission North West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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