This inspection was carried out on 22nd September 2010.
CQC has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.
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.
Random inspection report
Care homes for older people
Name: Address: Holmer Care Centre Leominster Road Hereford Herefordshire HR4 9RG The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sarah Blake Date: 2 2 0 9 2 0 1 0 Information about the care home
Name of care home: Address: Holmer Care Centre Leominster Road Hereford Herefordshire HR4 9RG 08453455745 01432342390 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs S Roberts,Mr Jeremy Peter Ewens Walsh Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 49 Number of places (if applicable): Under 65 Over 65 0 0 dementia mental disorder, excluding learning disability or dementia Conditions of registration: 49 49 The maximum number of service users who can be accommodated is: 49 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 49, Mental disorder, excluding learning disability or dementia (MD) 49 Date of last inspection 2 0 0 7 2 0 1 0 Care Homes for Older People Page 2 of 9 Brief description of the care home Holmer Care Centre is on the outskirts of the city of Hereford. It is owned and managed by The Holmer Partnership, Blanchworth Care. The Home was first opened in December 1991. It is a Victorian property that has been extended to provide a Care Home with nursing for a maximum of 49 older persons over the age of 65 years, of both sexes, who have dementia or a mental disorder. Twenty nine bedrooms are single occupancy, eighteen have en-suite facilities. The Home has a passenger lift. The Home operates a locked door policy, as indicated in the Homes Statement of Purpose and Service User guide. There is information literature describing the service displayed at the home and copies are available on the Providers website address. New residents receive a copy of this information and it also forms part of staff induction packs. Details of fees and additional charges are available from the Providers website address. A copy of this report can be viewed at the home. Care Homes for Older People Page 3 of 9 What we found:
We stopped awarding quality (star) ratings under the Care Standards Act 2000 on 30 June 2010. No new ratings have been awarded since that date. This report should be read in conjunction with other reports of recent inspections of Holmer Care Centre. We carried out this inspection to check whether or not the home had complied with two immediate requirements which we had made on 17 September 2010. These requirements had been made because we had found areas of concern which put people at high risk of harm or injury, which had not been addressed since they were first identified in July 2010. One inspector spent two hours at the home, observing how staff provide care for people, talking to staff, and checking care records. Our judgment is that the home has not complied with either of the immediate requirements. This is extremely serious, as it means that the providers are failing to protect people in their care. We have informed Herefordshire Council of our ongoing concerns, under their procedures for the protection of vulnerable adults. We have grouped our evidence under headings, to make it easier for people to find relevant information. PRESSURE AREA CARE At our previous inspections, we had found evidence that the home does not always manage pressure area care safely. We had made an immediate requirement at our visit on 17 September 2010 that the home must ensure that pressure area care was managed safely. We saw that someone was sitting in a wheelchair in the dining room. We already knew that this person had a pressure sore, so we checked the care records. The care plan stated ensure he sits on a pressure relief cushion. We saw that the person was not sitting on a pressure-relieving cushion. A member of staff confirmed that the person had been sitting in the armchair for over half an hour without any pressure-relieving equipment. We checked the care records for another person who had been assessed as being at very high risk of developing pressure sores. The care plan stated use a seat cushion. We saw that the person was sitting in a wheelchair and that there was no pressure-relieving cushion in the wheelchair. This places people at very high risk of harm, as the care plans are not being put into practice. It also raises concerns about how much staff understand about how to protect people from the risk of pressure sores. MOBILITY At our previous inspections, we had seen some very unsafe moving and handling practices at the home, and we had made several referrals to Herefordshire Council under its procedures for the protection of vulnerable adults.
Care Homes for Older People Page 4 of 9 We observed staff carrying out a transfer using a hoist. They explained clearly to the person what they were about to do. The sling was placed in position so that the persons arms were outside the sling. As the hoist was raised, the sling pulled the persons arms upwards, putting pressure on the underarm area. This placed the person at risk of injury to shoulders and soft tissues. At our last inspection on 17 September 2010 we had seen staff using a sling which was too big for the person being hoisted, and this had placed them in imminent danger of falling out of the sling. We checked the records for this person and we saw that a new assessment had been carried out and the care plan now showed that a smaller sling should be used. We asked staff which sling they would use and they told us that they would use the larger sling. We saw a list of sling sizes which was in the storage area where the hoists were kept, and this list showed that the person needed the larger size sling. Therefore the instructions for staff were not clear, and there was a risk that the wrong size sling could have been used. We looked at the care records for another person who needs assistance to mobilise. The care plan stated may need standing hoist. We asked staff how they transfer this person. They told us that the person needed a full hoist with a medium size sling. We saw that the persons weight had been recorded as 55.5kg, which is below the manufacturers minimum weight for a medium size sling. Therefore the records do not give accurate instructions for staff, and staff are using equipment which is not the correct size for the person. We continue to have serious concerns about the standard of care provided to the very vulnerable people at Holmer Care Centre, and we will be working closely with Herefordshire Council and Herefordshire Primary Care Trust to ensure that people are safe. What the care home does well: What they could do better: 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 set out on page 2.
Care Homes for Older People Page 5 of 9 Care Homes for Older People Page 6 of 9 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 7 of 9 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 8 of 9 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 Helpline: 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 9 of 9 - 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!
