Inspection on 19/03/07 for Holmer Court

This inspection was carried out on 19th March 2007.

CSCI 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 CSCI judgement.

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

Holmer Court 08/01/10

Holmer Court 09/02/09

Holmer Court 08/01/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holmer Court Attwood Lane Holmer Hereford Herefordshire HR1 1LJ Lead Inspector Philippa Jarvis 19 th Key Unannounced Inspection & 22nd March 2007 09:00 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 Holmer Court DS0000067474.V329897.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. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmer Court Address Attwood Lane Holmer Hereford Herefordshire HR1 1LJ 01344891259 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) showard@ashberry.net Ashberry Healthcare Limited Manager designate in post. Not yet registered. Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (32), Old age, not falling within any other category (32) Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st March 2006. Brief Description of the Service: Holmer Court is a large Georgian house with modern extensions, situated on the outskirts of the city of Hereford. It is registered to accommodate up to 32 older people whose care needs may arise from frailty due to the ageing process, physical disability, a dementia illness or other mental disorder. All rooms are single, apart from one, which is shared by two people. Twenty rooms have en-suite facilities. There are a range of communal rooms and good-sized gardens that are accessible for service users. The home was bought by Ashberry healthcare Ltd in July 2006 and this is the first inspection of the service since this provider took over. The current weekly fees are between £375 and £446 a week. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home has not had a registered manager since September 2006. The manager designate has submitted an application for registration to the commission and this is in the process of being considered. The inspection took place over two days, the first was unannounced, and the second day was prearranged with staff. During the two days some records and policies and procedures were inspected. Some residents and staff were spoken with and general observations were made of the premises and life in the home. There were also discussions with the manager designate. What the service does well: Holmer Court is a well presented home, set in attractive gardens that are secure and accessible to the residents. Residents are also able to bring their belongings into their bedrooms and many of those seen looked homely and well personalised. The home is clean and fresh. Positive comments received about Holmer Court included: “If I want something staff are always willing to help with it.” “I always feel happy to talk to the staff. They are very helpful.” “I am quite happy.” “They’re always about and always have time for you.” “My family and I are very satisfied with our father residing at Holmer Court.” “I have always found the staff very helpful, patient and kind and have never witnessed any situation which has given me cause for concern.” There are good levels of staff on duty. Staff are friendly and visitors are made welcome to the home. Residents and a relative said that that the staff are approachable and helpful. Staff speak to the residents in a pleasant manner and explain what they are doing. Residents said that they feel free to speak to the staff or the manager if there is something that they want changed or have concerns. The residents enjoy the food provided and plans are in hand to upgrade the dining room to make it a more pleasant and suitable environment. The residents also enjoy the activities that are provided on a regular basis. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 6 Holmer Court has satisfactory policies and procedures about safeguarding people from abuse and neglect. Staff have been trained in t his area. The home has involved the local police to talk to residents about keeping their belongings safe. What has improved since the last inspection? What they could do better: 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. Holmer Court DS0000067474.V329897.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 Holmer Court DS0000067474.V329897.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Interim care is not provided at Holmer Court. Quality in this outcome area is adequate. Staff obtain adequate information about a persons’ needs so that they can be sure that they can offer them the care that they need. The written information available for residents needs some attention to ensure that it is suitable for their needs and that it is always provided for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents are provided with a Service User Guide. Both this and the Statement of Purpose do not contain the full range of information required by standards and regulation. The language in the Service User Guide is not user friendly and it is not available in alternative formats for example for those who have a visual impairment. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 9 Holmer Court has a contract available for residents. Three that were requested during the inspection had not been signed by the people living in the home. The files examined all contained an assessment of needs that had been carried out before admission. The manager designate said that prospective residents are always encouraged to come and look round the home before deciding whether to come and live there. When people move in it is always on a month’s trial basis so that they can decide whether they like it and the home can confirm that they can meet their needs. The home also ensures that it receives a copy of the care needs assessment from the social services department if there is a social worker involved. The information contained in these documents forms the basis of the care plans. Holmer Court DS0000067474.V329897.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. The quality of the care records needs to continue to develop so that they detail all relevant information and provide staff with a sufficiently robust framework to make sure that residents receive the care that they need and that their wishes are taken into account. The quality of the personal care received by the residents is variable and steps must be taken to ensure that the staff carry out all expected care tasks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a plan of care. These have the potential to be a useful document but their use is in the process of development. The intention is that appropriate information is recorded in these on a daily basis. This practice needs to be consolidated to ensure that relevant information is not missed. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 11 There was evidence of issues that should have been recorded during the inspection that was not detailed in any record. Attention needs to be taken to ensure that the care plans are translated into action plans for the staff to follow. There was no evidence of the involvement of the residents and their relatives in the preparation and content of the plans. The extent to which residents had been helped by staff to look their best varied. Some residents were observed to have dirty teeth. Most looked well groomed but during a mid morning tour of some of the bedrooms, dry bars of soap and dry toothbrushes were observed on washbasins indicating a lack of attention to personal hygiene and mouth care. This was further confirmed from the bath log, which indicated that the frequency of bathing was variable. Relatives who responded to the questionnaire generally expressed their satisfaction with the care their relative received although one did comment that more than one bath a week would be appreciated. Systems need to be put into place to monitor the tasks carried out by the care staff. One relative spoken with said that his mother was always clean and well presented. Some people living in the home need help with mobility and there were moving and handling and falls risk assessments in place. The manager was aware of the need to review the assessments following a fall although the staff did not reliably carry this out. The home has equipment available to assist with moving and handling needs. The home also assesses needs in other appropriate areas such as skin care and nutritional needs. Residents’ weights are recorded monthly as part of this process. The home was careful to record the outcomes of appointments with health care professionals. Residents spoken with expressed their confidence in the approach of the home to ensuring that they received good health care attention. The home has recently carried out an internal audit of medication systems and this is good practice. This had identified certain shortfalls in their practice that they had since corrected. The findings of this inspection showed that most aspects of the management of medication are undertaken appropriately. It was however observed that there were packets of medication in the trolley that had not been dated when they were opened and that there were medications in peoples’ rooms that had been opened and not been dated. In some cases there was more than one open medication and some looked old. Staff who are involved in the administration of medication have received formal training. The approach of the home to ensuring that residents are treated with dignity and respecting their privacy is good. There is only one shared room and this has a screen. Health care appointments are undertaken in peoples own rooms. Staff were observed to speak with residents in a respectful manner. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15. Quality in this outcome area is good. Staff work hard to make life enjoyable and interesting for the residents. Residents receive a wholesome and nutritious diet and they are able to exercise choice over what they eat. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holmer Court has a friendly atmosphere and several residents said that the staff are kind and helpful. One resident said “The staff are very good and kind to me and help in any way they can.” Visitors can come to Holmer Court at any reasonable time and residents said that they were always made welcome. The home has a variety of activities that are carried out formally in the afternoons and staff are expected to spend time recreationally with the residents at any time during the day when they have time available. On the days of the inspection residents were observed making Easter biscuits and Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 13 bonnets. Board games were also being played. From observation it was pleasing to see that staff did have time to spend with residents and that they were not just kept busy with personal care and domestic tasks. Photographs of some previous events showed that considerable effort had been put into making activities lively and interesting. Comments were received from relatives about the increase in activities and outings over recent months. There was little information in resident records about their personal interests. This would help staff to tailor activities to individual needs and preferences. Residents moved around the home as they wished. The environment is secure including the large gardens. People were seen to go outside for a stroll and they were appreciative of the facility that these provided. The residents all expressed their appreciation of the food provided in the home. A number of residents commented that the meals have improved since the new chef started. There is a choice for breakfast and tea. There is one main meal provided at lunchtime although the cook asks each person able to make a choice whether they would like an alternative. The meals are well presented including those for people on a soft diet. The chef has not done any training in the nutritional needs of older people. Staff are available to assist residents where appropriate. The dining space is a pleasant, light room. The furniture is not suited for the needs of the client group and the manager designate said that new furniture had been ordered. Residents are able to eat in their own rooms if they choose. Drinks are available throughout the day and one resident said that he often asks for a drink in the middle of the night and the staff always prepare one for him. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 14 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): 16 and 18. Quality in this outcome area is good. Residents know who they can speak to if they have a concern although written information is not readily available. Staff receive the training they need to understand what to do if they think that a person may be suffering from abuse or neglect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints log and this showed that the home had received one complaint since the last inspection and that they had dealt with appropriately. There is a complaints procedure. This procedure indicates that details of how to raise concerns are displayed around the home. These are not displayed and there is only a small paragraph in the Service User Guide for residents to access. Residents surveys indicate that they know who to talk to in the home if anything is concerning them and those spoken with said that they would feel able to raise issues with staff at an early stage before they became a complaint. There was evidence that the manager designate had taken a robust approach following a report of mislaid money in the home and on the first day of inspection an arrangement had been made for the local community police Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 15 came to talk with residents and staff about approaches to keeping their belongings safe. There is a policy in the home about adult protection and staff have received training with regard to this. The home has policies and practices in place regarding the management of residents’ finances. The home is able to maintain the safe and secure storage of residents’ valuables if required. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 16 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): 19 and 26. Quality in this outcome area is adequate. Most of the accommodation is pleasant and comfortable for residents to live in. Some attention is needed to make sure that it is of a good standard throughout. Infection control arrangements in Holmer Court are generally satisfactory although care needs to be taken to ensure that adequate safeguards are in place throughout the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the building was made. This showed that most areas of the home are clean and well maintained. The residents comment cards all said that they found the home clean and fresh. Residents rooms are personalised with their own belongings. Some shortcomings were noted. There were some Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 17 soiled toiletry holders in residents rooms and one bed was seen that had a polythene cover on it. This had not been removed following purchase, although it was unnecessary as the mattress had a protective cover, and would have been hot and uncomfortable to sleep on. Several curtains were falling off their rails. The dining room acts as a thoroughfare to one side of the house and this area becomes very congested at mealtimes with staff, residents and the meal trolley all using the same limited space. There are two lounges, one of which is newly decorated and would benefit from the inclusion of some homely items. There are large, pleasant gardens, with an extensive patio area where residents can sit. The manager designate has plans to develop these to provide more access and recreation for the residents. One relative in their comment card suggested that the provision of more rails in the garden (and in the house) would allow and encourage greater access for those with mobility problems. The staff work hard to ensure that maintenance checks are kept up to date. Work was being undertaken to complete work required following a recent fire safety inspection. The laundry is sited in an internal room within the home and fitted with appropriate equipment. The room was very hot on the day of inspection. It was noted that the door was left open to allow air into the room; this also allows residents to enter the laundry. There is limited floor space for associated work such as ironing. Appropriate infection control measures are in place in the laundry and there is a separate sluice facility on the second floor. One toilet had yellow bag for soiled incontinence pads on the floor; this was unhygienic and unsightly. Staff confirmed that there are always sufficient gloves, aprons etc for infection control. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 and 30. Quality in this outcome area is adequate. Staffing levels and deployment are suitable for the residents needs. The evidence was not available to confirm staff recruitment procedures. The training programme for staff needs to continue to develop to ensure that they have the right knowledge and skills to carry out their role. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels in Holmer Court are sufficient for the care needs of the residents, and the size and layout of the building. Staff confirmed that the workload is manageable and most of the comment cards received from residents and their relatives indicated that there were adequate staffing arrangements most of the time. The residents spoken with said positive things about the staff. Observation of their practice showed them to be polite, caring and to assist the residents in an unhurried way. All the comment cards received said that the care staff always listen to what they say and act on this. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 19 Three staff files were identified for examination. References, evidence confirming identification and checks from the criminal records bureau were in a locked cupboard and the manager designate did not have access to this. The evidence needed for inspection of these areas was therefore not available. The file for a newly appointed member of staff was requested. This content in this did not meet the standard required. The application forms would benefit from upgrading for example there was no information in them about training that applicants have completed. The manager designate has not reviewed the staff files that were in place before her appointment and is therefore unsure of whether they meet a satisfactory standard. New staff have a mentor to support and guide them in their first weeks in the home. The file of one new staff indicated that they had completed the common induction standards in one day. The content of this training needs review as the standards are designed to take up to twelve weeks. Also they did not contain any health and safety training and this is part of the induction elements. The home provides training for staff and there is evidence that some core areas are being addressed appropriately. There was however no evidence of any health and safety or infection control training for staff n the home. There was also a shortfall in first aid training. Consideration should also be given to ensuring that all staff receive training in working with people with dementia illnesses. The manager designate has produced a training priority document for the service with proposed timescales for completion. The home is actively promoting NVQ training and over 50 of care staff have achieved this qualification. A further six staff are scheduled to start NVQ training at the end of March. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 36 and 38. Quality in this outcome area Is adequate. The service has gone through an unsettled period with both the provider and the manager changing. This has lead to aspects of the management of the service needing attention to ensure that appropriate standards are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager designate has submitted an application to be registered in this capacity. She has previous senior experience in a care home although she has not previously been registered. She has not completed a relevant Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 21 management qualification and has stated her intention of completing this. The area manger for the organisation supports her in her role. There are aspects of her practice where the manager needs further guidance to help her to continue to develop a professional management approach. She is willing and enthusiastic to carry out the role well. Certain elements identified as being in need of attention at the end of the first day of inspection were in the process of being addressed by the time of the second visit, such as certain maintenance matters and monitoring of staff attention to residents personal care. The staff indicated that they found the manager designate approachable. There have been staff meetings for various staff groups since she took over including one full staff meeting. The administrator has the keys to the filing cabinet that contains the staff records. This compromised the outcome of one area of the inspection. Consideration should be given to the manager designate having access to a set of keys to all areas in the home. The home has a policy regarding quality assurance. The manager designate said that it is not active within the home although there are a number of elements of practice that do contribute towards quality monitoring, such as the Regulation 26 reports, the audit of food provision that has been completed and the internal medication audit. The record of management of residents money was available for inspection and the information detailed in this showed that the home has a suitable system for dealing with their accounts. The manager designate has not yet started a system of staff supervision. She said that she has plans to implement this. There is no staff appraisal. The approach to the management of health and safety needs development. Where aspects were in place these had been managed to a good standard: • Certain records about health and safety checks and tests were requested and these had all been carried out appropriately. • The accident book was well detailed and had been audited. • The approach to the management of fire safety. There were other aspects that needed attention: • There is no designated health and safety lead officer for the home and there were no risk assessments for safe working practices in the home. • There was also no lead person for first aid in the home with a first aid at work qualification. • There needs to be further health and safety and first aid training for staff in Holmer Court. Also the induction training does not include information on safe working practice topics. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 22 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 1 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 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 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 1 Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 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 OP1 Regulation 4&5 Requirement The registered person must ensure that the Statement of Purpose and the Service User Guide contain the information set down in the standards and regulations. The registered person must ensure that each person has a service user plan that sets out in detail the action, which need to be taken by care staff. They must ensure that all relevant information is recorded and taken into account in the service user plan. The home’s Whistle-blowing policy must clearly state how someone can raise concerns to appropriate bodies outside of the home and organisational structures. (Previous timescale of 01/06/06 not met.) The registered person must ensure that there is a thorough recruitment and selection procedure for all staff employed in the home. The registered person must DS0000067474.V329897.R01.S.doc Timescale for action 30/06/07 2 OP1 15 31/05/07 3 OP18 24 31/05/07 4 OP29 19 30/04/07 5 OP30 19 31/05/07 Page 24 Holmer Court Version 5.2 6 OP33 24 7 OP36 18 8 OP38 18 & 23 ensure that all members of staff receive training appropriate for their role and function within the home. Each member of staff should have a training and development assessment and profile to identify their individual training needs. Effective quality assurance and quality monitoring systems based on seeking the views of service users must be in place to measure success in meeting the aims, objectives and Statement of Purpose of the home. The systems should follow the outcomes outlined in Standard 33. (Previous timescale of 01/06/07 not met.) The registered person must ensure that care staff receive formal supervision at least six times a year. The registered person must ensure that the safety and welfare of the service users is promoted. This must include carrying out a risk assessment of safe working practices in the home and putting a programme into lace to ensure that staff have receive training in health and safety and in infection control. 30/06/07 31/05/07 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The registered persons should produce a Service User DS0000067474.V329897.R01.S.doc Version 5.2 Page 25 Holmer Court Guide in alternative formats suited to the needs of the residents. Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. Extracts may not be used or reproduced without the express permission of CSCI Holmer Court DS0000067474.V329897.R01.S.doc Version 5.2 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. 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