Inspection on 30/07/08 for Holme View

This inspection was carried out on 30th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holme View 21/08/07

Holme View 30/08/06

Holme View 22/11/05

Holme View 18/01/05

Holme View 14/10/04

Holme View 17/03/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Holme View Gillingham Green Holme Wood Bradford BD4 9DT Lead Inspector Caroline Long Key Unannounced Inspection 30th July 2008 09:30 X10015.doc Version 1.40 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 View DS0000033613.V369371.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 Older People. 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 View DS0000033613.V369371.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holme View Address Gillingham Green Holme Wood Bradford BD4 9DT 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) 01274 681682 01274 687205 City of Bradford Metropolitan District Council Department of Social Services Mr John Venner Care Home 37 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (37), Old age, not falling within any other of places category (37) Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2007 Brief Description of the Service: Holme View is owned by Bradford Metropolitan District Council and provides care for up to thirty-seven people. This includes people with dementia. Holme View is purpose built and the accommodation is arranged around four flats. All of the flats have a lounge and dining area/kitchen, and a communal bathroom and toilets. All bedrooms are for single occupancy. It is in the Holmewood area, on the outskirts of Bradford city centre. There are a few local shops nearby. The home is close to the city centre and the outlook from the rear of the building is open grassed area. There is a secure fence around the grounds of the home and there is a garden where people can sit out. On the 4th August 2008 the full fees were from approximately £435 per week, which people pay according to their financial assessment. The fee does not cover the cost of newspapers, hairdressing, taxi fares or private chiropody treatments. The Commission for Social Care inspection reports are available in the home. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. There has been a change of manager of at Holme View during 2007. The management are aware of what improvements are needed and are working towards improving the quality of the service provided. We found they were now listening to and responding to the views of the people living in the home and their relatives and they have made some improvements following the last inspection. People benefit from Holme Views capacity to offer temporary accommodation for people when they are unable to be looked after in their own homes due to the illness of a relative. This is what we used to write this report: • • • We looked at information we have received about the home since the last key inspection. We asked for information to be sent to us before the inspection, this is called an annual quality assessment questionnaire (AQAA). One inspector visited the home unannounced. This visit lasted over six hours and included talking to the staff and the deputy manager about their work and the training they have completed, and checking some of the records, policies and procedures the home has to keep. We spent time talking with and observing people who live in the home and talking with two peoples relatives. We looked at three people’s care records to check that a plan had been formulated which helped staff provide support to people according to their needs and wishes. • • What the service does well: People can visit the home before they make a decision about moving in. The arrangements are flexible enough to make allowances for people who need to move in quickly or may need longer to make a decision. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 6 A good choice of food and drinks are available. This ensures that people receive a varied and nutritious diet. One person said, ‘The food is very good’. ‘Visitors are made welcome.’ The home has a warm friendly atmosphere, where people are engaged and encouraged by staff to participate in social activities of their choice. This helps them maintain their social skills and independence. There is a clear and user-friendly complaints procedure and complaints are taken seriously. Arrangements are in place to measure the quality of the service, which includes feedback from people. This ensures that the staff continue to deliver care in the best interests of people who use the service. Relatives made very positive comments about the home and the care people receive. For instance: ‘Excellent, staff very helpful.’ ‘Very nice, staff are attentive and helpful.’ What has improved since the last inspection? What they could do better: Improvements have been made to the care plans however some still need to reflect the care being given and contain more information about people’s preferences. Risk assessments also need to be looked at to make sure they contain the necessary actions staff need to take to keep people safe. This is to make sure people receive a consistent standard of care. The monitoring of peoples’ weights needs to be improved and appropriate action needs to be taken if there is a change in weight. People need to be given their medication at the time it is prescribed. Refurbishment of the home needs to continue to provide people with a safe and comfortable and pleasant place to live. Where the home has to decide about whether a person is able to make a decision in their own best interests, they need to be sure the appropriate people are included, such as relatives, advocates, health professional and care staff and this is fully recorded. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 8 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 View DS0000033613.V369371.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 3 (Standard 6 - N/A, the home does not provide intermediate care). People who use the service experience good quality outcomes in this area Peoples’ needs are properly assessed prior to admission, which means that people know the home can meet their needs before they move in. This judgement has been made using available evidence including a visit to this service EVIDENCE: The deputy manager told us staff generally receive an assessment of people’s needs carried out by the social services care manager and visit the person before they move in to carry out their own comprehensive assessment. Following this they encourage people to look around the home and stay for a meal. People are offered the opportunity to stay for a trial period before they move in permanently. This helps the home to make sure it has the staff skills and equipment necessary to care for people properly and gives the person the opportunity to meet everyone and get a ‘feel’ for the home. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 10 We looked at two people’s records that had moved into the home recently both contained assessments of people’s needs, and information from the social services are managers. A relative told us staff had carried out an assessment before they moved in and described how staff had prepared the bedroom with personal belongings to make sure they settled quickly into the home. The staff records showed and staff said they had the necessary training to enable them to look after people properly. Some of the staff told us they had also recently completed a training course on dementia care. At the point of admission, people are given a contract that sets out the terms and conditions, and the fees. Two of these were found on people’s care files. It remains the case that people who stay temporarily in the home are not provided with a contract. This has again been highlighted as a recommendation. The home offers temporary placements for up to ten people, however the deputy manager explained they had found offering this number of temporary placements had a negative effect on the people who were permanently in the home. In response to this they were reducing the number of temporary people they will take and refurbishing one of the flats so they can be cared for without disturbing the people who live permanently in the home. When someone moves into the home for a temporary stay this can be due to an emergency in these circumstances staff rely heavily on the information provided by the placing authority, usually a social services care manager. They told us they have a comprehensive statement of purpose and service user guide, which is available in different formats to suit people’s needs. When we visited we were given a copy, this needs to be updated to reflect the changes in the staff and accommodation changes in the home. The home does not offer intermediate care. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. People who use the service experience adequate quality outcomes in this area. Some plans of care are not clearly written so staff do not always know how to best care for each individual person. Further work is also needed to make sure all identified risks are adequately recorded and show what action needs to be taken to minimise risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we visited the atmosphere was calm and staff were cheerful and attentive to people’s needs. Two relatives also made very positive comments about the home and the care people receive. For instance: ‘Excellent, staff very helpful.’ ‘Very nice, staff are attentive and helpful.’ Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 12 People were well cared for and the relatives told us this was always the case and peoples personal needs were carried out in a dignified way and peoples privacy was respected. At the previous inspection we had asked the staff to make sure care plans reflect the care being given and people’s weight to be monitored and recorded accurately and for appropriate action to be taken if there are any changes. We looked at three people’s care records to check that a plan had been formulated, which would help staff provide support to people according to their needs and wishes and whether weights were being monitored. We found that the standard of documentation varied a lot and depended on who had been involved in creating the record and was not always person centred. Two of the files did not contain people’s personal preferences or any indication that the care plan had been agreed with them or their representatives. Where an issue about people’s safety had been identified this was not included in two people’s care plans, and one did not have a risk assessment in place. The home were weighing people monthly and the deputy manager told us there were systems in place to monitor and identify any changes, however where one person’s record showed they had lost a considerable amount of weight this had not been identified or followed up. We talked about these issues with the deputy manager who agreed to review these people’s care. The home operates a key worker system and staff told us they generally work on the same units, which helps them to get to know people well and understand their personal preferences and needs. People who could not make their views known were observed interacting with staff during the visit. It was clear that staff knew them well enough to be able to understand what they needed and they responded to people who seemed distressed in a caring and attentive way. The home offers accommodation to people with dementia; this can mean people are not always able to make decisions in their best interests. To protect people’s rights the managers need to make sure they abide by the mental capacity act when deciding whether people are able to make decisions and whether those decisions are in their best interests. There was evidence from the records that people do have access to their general practitioner and the home is proactive in contacting the GP surgery. When we visited we saw both physiotherapist and district nurses within the home and one told us that the staff do seek advice when necessary. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 13 Medication is held in each of the four flats in locked cabinets, we looked at two of the flats at teatime and found one of the units had not given people their prescribed medication at lunch time the senior care immediately agreed to investigate this. The home does have a medication policy and there were monitoring systems in place to identify if any errors did occur. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15. People who use the service experience good quality outcomes in this area. People have access to activities of their choice. People are given a choice of nutritious drinks and meals when they request them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we visited there was a calm and relaxed atmosphere in the home. We saw people making choices about their daily lives and moving around the home freely. Some were involved in activities in the day centre, others were watching TV or reading and some were taken out to a quiz in the afternoon. Two relatives told us there were activities available in the home. There is a activities co-ordinator who works twenty-five hours per week, she told us she helps people both in groups and individually to take up activities of their choice. She also makes sure people from each flat visit the day centre to give them variety and to meet new people, examples of activities were dominos, quiz, knitting, reminiscing, sing-along, word searches. She also told us the home has a mini bus available each day and she likes to make sure people are offered regular trips out examples given were to the seaside and to Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 15 the local cafe. Also when there is an event such as Easter, or Halloween theme days are carried out. She also explained everyone’s preferred activities are recorded on an activities plan, which all staff can access. However when we looked at the records we did not find plans of people’s preferred activities but mainly an account of the activities they had carried out. People seemed to move about the home freely and had access to the day centre, one relative explained how their relative liked to go to the day centre to play pool and was allowed to keep their pet in the home. Also how they had a fridge so they could keep some of their favourite foods in the home. Two visitors said how welcoming the home was and that they were told they could visit when they wanted. The deputy manager explained how they hope to create a sensory room for people to use where they can relax and listen to music. When we visited before we asked the home to make sure people were able to practice their chosen religious faiths. This time we found that people’s faiths were documented in their care plans and arrangements were being made for both a priest to visit and for the local church to carry out regular services in the home. People did make choices about their daily lifestyle, however most of the bedroom doors were locked, to make sure no one else wandered into them. The deputy manager explained everyone had signed to say they wanted their room locked and one or two people did have their own key. A relative also described how their relative held a key to their room. The staff need to always be sure that locking bedroom doors is not carried out as routine or without the person’s permission, as it restricts access and limits the facilities of the home. We observed a meal and found the food to be hot and look appetizing people eating the meal said this was normally the case. Tables were set with cutlery, table cloths and condiments. People living in the home and their relatives said there was normally a choice at meal times and the food was generally very good. Staff were aware of people’s diets and people were helped with their food in a respectful manner, although in one flat plastic aprons were being used which do not promote people’s dignity. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 17 and 18. People who use the service experience good quality outcomes in this area. People have access to a complaints procedure and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People can raise any concerns or make any comments by writing them down and putting them in a suggestions box in reception. The deputy manager explained the home manager initially investigates any concerns and the operational manager investigates any further or serious issues. The complaints before January 2008 had been archived but a complaint that had been made recently had been responded to in the set timescales and resolved. Two relatives told us the managers were approachable and they would feel comfortable in raising any concerns. The managers are aware of how the mental capacity act affects their work when deciding whether people have the capacity to make decision. However the home needs to make sure that the appropriate people are always involved in deciding about a person’s capacity and any decisions are definitely made in people’s best interests. Where any decisions are made about people capacity these should be clearly recorded. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 17 The home has an adult protection policy and has involved Bradford Adult Protection Unit when safeguarding incidents have occurred in the home and have been proactive in informing and seeking advice from them. Staff told us they have received training about how to safeguard adults. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use the service experience adequate quality outcomes in this area. People live in a clean home, however more must be done to improve the decoration and remove the odours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built and meets people’s needs. It is split into four flats and each has a separate lounge, kitchen and dining room, there is also a day centre that people can use. When we visited we found a number of areas of the home were in need of new carpets and redecoration, also parts of the home lacked the homely touch and were quite sparse. The home was also not decorated in a way that would enable a person with dementia to navigate it easily for example all the Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 19 corridors and lounges were similar colours and did not have any memorabilia that people can use as guides. There were also unpleasant smells in some areas. However we were told people’s rooms were decorated with their own pictures and possessions and to help one person their bedroom door had been decorated a specific colour. The deputy manager also told us carpets were to be replaced to improve the smell and parts of the home were to be redecorated to meet people’s needs. The conservatory has now been completed. This leads out into a safe garden with raised flowerbeds. The deputy manager explained they hoped to change this into a dining area, as a way of encouraging people to use it more. When we visited last year we asked the home to make sure the bins in the kitchens and bathrooms to have lids to make sure hygiene standards are maintained. Bedrails to be maintained and a record kept of the checks being carried out to minimise the risk of accidents and make sure they are properly fitted and in safe working order. Also for the extractor fan in the kitchen to be cleaned. The deputy manager confirmed everything we asked for had been carried out. The home was very clean and the cleaner was seen to be both helpful and friendly to the people living in the home. A relative told us the home was always clean. The manager had completed an assessment form for the home, which includes confirmation that all health and safety checks are done on equipment and certificates are in place to show that the electrical hardwiring, gas, hoists and lifts are in safe working order. There is a policy on the prevention of infection and the management of infection control. The guidance is followed and systems are in place to prevent the spread of infection. Gloves and aprons were available throughout the home. However, the annual assessment questionnaire shows not many of the staff has received infection control training. To prevent the spread of infection all staff need to have infection control training. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. The staff team provide people with the care and support they need, however the managers need to review staffing numbers to make sure people are safe on a night. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments made by the relatives about the staff at Holme View were very positive for instance:‘Staff are very helpful, kind and attentive.’ ‘Staff include everyone.’ We saw staff were warm, kind and respectful to people in the home and attentive to people’s needs. Despite the busy day they created a calm and homely feel in the home. Staff told us there are normally enough staff on duty and the relatives also said this. There is one carer on each of the four units, a carer who is shared between the flats and a senior carer, this is for the mornings and the afternoons and they were supported by cleaning staff and a chef. However staff did appear very rushed and on a night there are only three staff on duty Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 21 two upstairs and one down stairs and there are two people who need regular monitoring for their safety. Some of the people who live in the downstairs flats also need the help of two members of the staff. This was discussed with the deputy manager who agreed to review the staffing numbers at night whilst these people need monitoring. At our last visit we asked for there to be a record of staff training, this enables the managers to identify when staff training needs updating. This has been completed and maintained but we found there are areas of training which staff need updating such as mobility assistance, medication, food hygiene and infection control. However two staff told us they had completed most of their mandatory training, and had received training in dementia care but not in managing challenging behaviour. Improvements still need to be made to make sure all staff training is kept up to date so that staff have the skills they need to do their job properly. Staff records showed that new people are having an induction that takes four weeks and includes health and social care values, person centred care, equality and diversity, medication, risk assessment, adult protection and mobility assistance. The home continues to try to recruit to vacant posts. Three staff files were examined to see if the home carries out proper interview, recruitment and additional checks to make sure staff are suitable to work with vulnerable adults. We found staff have been recruited centrally by the local authority, this means that the manager at Holme View has not always been part of the recruitment process and when this had happened the recruitment process had not been thorough. However we were told the managers were now involved in the recruitment. When we looked at two other staff records where the managers were involved we found this was no longer happening. The managers are responsible for keeping people safe and need to be always sure that people are not employed before they have received and agreed suitable references. The deputy manager explained staff have regular staff meetings and this was confirmed by two members of staff. During our visit senior care staff held one of their regular meetings. The home have told us eighteen out of twenty four staff have completed their national vocational qualification in care level two or above, this qualification provides staff with the basic skill to carry out their job properly. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. Although the managers are working towards improving the home, the owners need to provide a stable and consistent management team to enable it continue to improve. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the previous inspection the owners were asked to register a manager with the Commission this has not been carried out and the home has now a further temporary manager. The temporary manager has a wealth of experience, and staff and a relative told us of the improvements she has made. However to provide both the people living in the home and staff with consistency there still needs to be a permanent manager in post who is registered with us. Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 23 The annual quality assurance form was completed and returned to us, it provided us with most of the information we needed. The staff told us the manager and deputy manager are approachable and worked well with them. There are daily handovers to make sure the staff are well informed about people living in the home. The manager is supported in her role by the assistant manager for residential and day care, who meets with her at least monthly to provide supervision. We asked the home to make sure staff were receiving regular supervision, staff told us they were now receiving supervision, however the records show further improvements need to be made to make sure this is at least every two months. We were told the home has residents meetings and a relative told us they have recently attended a relatives meeting, which they had found most informative. We were provided with a copy of the recent quality questionnaire which showed that people were happy with the service provided at Holme View and that the management listens to people’s views and responded to them. This helps the managers to make sure they are providing people with a service they want in the way they prefer. A representative of the organisation visits the home every month to monitor the quality of the service and provide support to the manager. We did not look at the finances when we visited but the deputy manager explained the systems had not changed since the last inspection and the home was expecting a financial audit from the finance department of Council shortly. In the annual quality assessment questionnaire the manager has written that that the annual checks for health and safety are in place, and regular health and safety committee meetings are held within the home. Holme View DS0000033613.V369371.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 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 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 X X 3 Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement You must make sure care plans reflect the care being given. Additional work is required to make sure staff know what to do in circumstances where people are at risk. People’s weights must be monitored and recorded accurately. Appropriate action must be taken if there is a change in weight. Previous timescale of 29/10/07 has not been met You must make sure people receive the correct medication at the appropriate times. You must abide by the Mental Capacity Act and make sure the appropriate people are involved when deciding whether people have the capacity to make decisions about their lives. You must keep the home free from offensive odours. This is to protect people’s dignity and provide them with a pleasant DS0000033613.V369371.R01.S.doc Timescale for action 30/07/08 2 OP9 13 (2) 30/07/08 3 OP17 12 1 (a) 30/07/08 4 OP26 16 (k) 01/09/08 Holme View Version 5.2 Page 26 place to live. 5 OP27 18 Staffing levels must be reviewed to make sure that there are sufficient staff on duty to meet the needs of people using the service at all times. You must make sure staff receive the necessary training to enable them to care for people properly and safely. 30/07/08 6. OP30 18 01/09/08 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 OP2 Good Practice Recommendations The registered person should make sure that short stay people are issued with a contract setting out the terms and conditions of their stay. To make the home comfortable and safe and to meet people’s needs you should: • Provide new carpets for areas where the carpets are old • Continue with a programme of redecoration that will enable a person with dementia to navigate it easily around the home. To provide consistent leadership there should be a permanent manager recruited to the home who is registered with the us. 2 OP19 3 OP31 Holme View DS0000033613.V369371.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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