Inspection on 08/11/06 for Holmes House Care Home

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Holmes House Care Home 07/02/06

Holmes House Care Home 27/04/05

Holmes House Care Home 25/10/04

Holmes House Care Home 18/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

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

CARE HOMES FOR OLDER PEOPLE Holmes House Care Home Kenilworth Road South Wigston Leicestershire LE18 4UF Lead Inspector Chris Wroe Unannounced Inspection 8th November 2006 12:25p 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 Holmes House Care Home DS0000058967.V318348.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. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmes House Care Home Address Kenilworth Road South Wigston Leicestershire LE18 4UF 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) 0116 2782214 0116 2789379 Collegia Care Ltd Linda Georgina Warren Care Home 48 Category(ies) of Dementia - over 65 years of age (25), Learning registration, with number disability (4), Mental disorder, excluding of places learning disability or dementia (6), Old age, not falling within any other category (48), Physical disability (10), Sensory impairment (4) Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within category DE(E) may be admitted to Holmes House when 25 persons who fall within category DE(E) are already accommodated within the home No person falling within category MD(E) may be admitted to Holmes House when 6 persons who fall within category MD(E) are already accommodated within the home. . No person falling within category LD(E) may be admitted Holmes House when 4 persons who fall within category LD(E) are already accommodated within the home. No person falling within category PD(E) may be admitted to Holmes House when 10 persons who fall within category PD(E) are already accommodated within the home. No person falling within category SI(E) may be admitted to Holmes House when 4 persons who fall within category SI(E) are already accommodated within the home. No person falling within category OP may be admitted to the home when 48 persons who fall within category OP are already accommodated within the home. To be able to admit the named person of category MD named in variation application number V34211 dated 14th August 2006 into Holmes House 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Holmes House Care Home is a care home offering accommodation for up to forty eight older people (over 65 years of age). The additional needs of people choosing to move to the home may include physical disabilities, mental disorders, dementia, sensory impairment and learning disabilities. The home is owned and managed by Collegia Care Limited. The home is located in South Wigston, approximately fifteen minutes by car from the Motorway (M1 and M69 junction). It is situated five minutes by car from the main high street in South Wigston, which has a range of local shops and facilities. The building itself is a modern purpose built property set in substantial grounds. The immediate area surrounding the home is a residential area. All areas of the home are accessible for people with limited mobility, and the home is equipped with a slow moving lift. There are grounds, which residents can access. Parking is available to the front of the property. The range of fees is currently £440 to £550. Additional charges are made for Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 5 chiropody, hairdressing and newspapers. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included a visit to the service. The inspector visited the home on 8th November 2006. The visit lasted for four and a half hours. The Registered Manager, Ms Lin Warren, assisted the inspector during the visit. The inspector used a method called ‘case tracking’ during the inspection. This means selecting a sample number of residents and looking at the care given to residents in different ways. The ways this was done are: • talking to the residents • talking to staff and the manager • watching how residents are given support • looking at written records. The Commission for Social Care Inspection is carrying out a national pilot scheme at this time. This inspection included a ‘thematic enquiry’ as part of this scheme. This means that the inspector asked some set questions about certain themes to a sample of residents in the home. The inspector gave information and asked for the consent of residents before asking them the set questions. The inspector spoke with five people who live in the home. In addition, we sent out service user comments cards to ten randomly selected residents. Eight comments cards were completed and returned to us – some of these had been filled in by relatives on behalf of residents. Together with comments from people spoken with during the inspection, these form a sample of views. The report includes the views of people who live in the home. In the main, residents in the home were happy about the care given by staff. They felt the home was comfortable and they have what they need. All the key standards were checked during this inspection. The information below is based only on those aspects checked in this inspection. Individual detail has been kept out of the report, to make sure it is kept confidential. What the service does well: The manager carries out assessments for people who might like to come and live in the home, to find out about their care needs and whether the staff will be able to support them. Staff have training to enable them to meet the needs Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 7 of people living in the home, such as moving and handling, to help them to be able to move and lift people safely. Everyone we spoke to said that they felt the right choice had been made in moving to the home. Everyone living in the home has a contract and terms and conditions. The service user guide has information about the home in it, for example it describes the type of care needs the staff can meet and what accommodation people can expect. When people come to visit the home, the manager gives them a checklist, which includes information about the range of fees. Staff write care plans about residents, which give information about their needs and how staff in the home will meet them. Staff understand and meet the care needs of residents. Staff keep records about accidents or anything that happens in the home, which could affect the well-being of residents. Different risk assessments are carried out, to make sure that residents are looked after properly and are able to be safe in the home. Staff make sure that residents see a GP or other health professional if they are unwell. Staff who give out medication have had training. The record-keeping in relation to medication is generally good in the home. The manager also carries out checks of the medication process and stocks. Staff treat residents with respect. Staff try to help residents to be as independent as they are able to. Residents are able to make choices in their daily lives. There is an activities co-ordinator working in the home, who offers different things for people to do. The manager and staff try to involve people from the local community in the home. Students from the local college come to spend time with residents. Residents can have visitors to see them when they choose to. They are able to see them in one of the lounges or in the privacy of their own rooms. One relative told the inspector that they were made to feel welcome in the home. Residents are able to take part in religious worship if they want to – services are held weekly in the home, and staff will support residents to make contact with people from their faith. Relatives mainly handle the financial affairs of residents. Residents told the inspector that their relatives dealt with fees and contracts with the home. Residents are supported to have the right to vote if they want to. The menus show that a varied and nutritious diet is given to residents. Residents told the inspector that they like the food, and that they are able to have a choice. The inspector saw that at lunchtime staff were supporting residents who needed. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 8 Staff were able to tell the inspector about the procedures that should be followed if there are any concerns about harm to residents. There is a complaints procedure in the home and the manager investigates complaints within 28 days. Residents told the inspector that they felt able to raise any concerns with the manager or with staff. All areas seen in the home were clean and tidy. Residents are able to have their own possessions in their bedrooms. The manager makes sure that safety precautions and checks are carried out in the home. There is a fire risk assessment in place. There are systems in place for making sure laundry is done efficiently. Staff told the inspector about safety precautions for controlling the spread of infection, and there are procedures in the home to make sure that staff work safely. There are a minimum of five carers on duty during the day. Staff are recruited properly, and that the manager makes sure checks are carried out so that she can be confident that staff are safe to work with residents – such as Criminal Record Bureau checks. There is an ongoing staff training programme in the home. Staff learn a range of different skills to help them to improve their ability to care for residents in the home. The manager runs the home in a positive and open way. Staff feel that they can approach the manager and be well supported. Attention is paid to making sure that the quality of service provided in the home is good. Residents are asked in various ways for their views about the running of the home. The manager carries out quality assurance checks of different aspects of the service, including spot checks. The provider of the service carries also carries out checks and prepares reports for the Commission for Social Care Inspection on a monthly basis. The manager makes sure that any money held in the home for residents is looked after properly. Staff keep records and receipts of money spent on behalf of residents. The manager and staff make sure that the home is run properly, keeping residents safe. Staff have training in safety aspects, such as food hygiene and infection control. There are procedures in place, which tell staff how to work safely. What has improved since the last inspection? Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 9 The manager has improved the policies and procedures, which tell staff about medication and how it should be given out and recorded, so they are much clearer for staff. The manager has introduced new contracts for one to one supervision with staff, to make sure that staff are properly supported. 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. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 10 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 Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 11 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): 3 (6 is not applicable at this time) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a good admissions procedure to the home. EVIDENCE: One person we spoke to said that they had received information about the home before moving in, and that they had a chance to come and live in the home for a trial period to see how things went. Most people we spoke with said that relatives had been involved in finding a place for them to move to and in sorting out contracts and fees. Everyone we spoke to said that they felt the right choice had been made in moving to the home. All eight people who responded in comments cards said that they had received enough information about the home before moving in, to enable them to make a choice about whether it was the right place for them. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 12 The manager carries out assessments for people who might like to come and live in the home, to find out about their care needs and whether the staff will be able to support them. Staff have training to enable them to meet the needs of people living in the home, such as moving and handling, to help them to be able to move and lift people safely. Privately-funded residents and people who get help to pay their fees have contracts and terms and conditions. Copies of contracts are in care files. Everyone who returned comments cards said they had received a contract (or one was due following trial period). The service user guide has information about the home in it, for example it describes the type of care needs the staff can meet and what accommodation people can expect. When people come to visit the home, the manager gives them a checklist, which includes information about the range of fees. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 13 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, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff pay attention to meeting the health and care needs of residents, which helps residents to feel well looked after. EVIDENCE: Staff write care plans about residents, which give information about their needs and how staff in the home will meet them. Staff make daily records about how people are and what they have been doing each day. The people we spoke with during the visit to the home said that they were not really involved with the care plans – they did not really have an interest in them. What mattered to people was the care they received from staff, and they were all very happy about this. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 14 Five people said in comments cards that they always receive the care and support they need; two said they usually do, and one person that they sometimes do. Staff keep records about accidents or anything that happens in the home, which could affect the well being of residents. Different risk assessments are carried out, to make sure that residents are looked after properly and are able to be safe in the home. Staff work with specialists from the health authority to help to prevent residents from having falls. This is good practice, and records kept in the home show a low number of reported falls. Staff make sure that residents see a GP or other health professional if they are unwell. Staff also make sure residents have other healthcare support, for example for eye care and dental care. Staff who give out medication have had training. The record-keeping in relation to medication is generally good in the home. The manager has improved the policies and procedures which tell staff about medication and how it should be given out and recorded, so they are much clearer for staff. The manager also carries out checks of the medication process and stocks. We noted two minor issues, which the manager could make sure, are improved • For one resident the record was not clear about whether one type of medication was something which must be given every day (and so it would be concerning if the resident regularly refused) or whether it was something the person could choose to have if they needed it – in which case the record needs to show this • In some cases, staff had handwritten medication details and doses on the record sheets, which could lead to mistakes. Staff treat residents with respect. Staff try to help residents to be as independent as they are able to. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 15 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, 15’ Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to have a good lifestyle in the home. EVIDENCE: Residents are able to make choices in their daily lives. There is an activities co-ordinator working in the home, who offers different things for people to do. Some people like to get involved in activities such as bingo, music, armchair dancing, sing-along, and poetry reading. Some people prefer to spend time on their own or sitting with friends. The manager and staff try to involve people from the local community in the home. Students from the local college come to spend time with residents. There are bigger events held at the home – an autumn fete was recently held, and a Diwali and bonfire night celebration. Out of eight comment cards received, four people had commented that there are always enough activities, three people that there usually are enough, and one person that there sometimes are enough. One person said that although activities were offered they did not always choose to take part. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 16 Residents can have visitors to see them when they choose to. They are able to see them in one of the lounges or in the privacy of their own rooms. One relative told the inspector that they were made to feel welcome in the home. Residents are able to take part in religious worship if they want to – services are held weekly in the home, and staff will support residents to make contact with people from their faith. There are married couples living in the home. Currently the home does not have a policy about how they might support people to develop friendships and relationships in the home. Relatives mainly handle the financial affairs of residents. Residents told the inspector that their relatives dealt with fees and contracts with the home. Residents are supported to have the right to vote if they want to. The menus show that a varied and nutritious diet is given to residents. Residents told the inspector that they like the food, and that they are able to have a choice. The inspector saw that at lunchtime staff were supporting residents who needed help sensitively. Of eight comments cards received, three people commented that they always like the meals in the home, four people that they usually like them, and one person that they sometimes like them. One relative commented: ‘Food seems very good. My dad looks well fed.’ Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 17 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are mostly protected by procedures and good staff awareness regarding complaints and safeguarding from harm. EVIDENCE: Staff mostly make sure that any serious events are reported to other organisations like the Commission for Social Care Inspection, which they must do by law. We reminded staff that any incident should be reported, where the behaviour of someone who has dementia causes a risk to other residents. Staff were able to tell the inspector about the procedures that should be followed if there are any concerns about harm to residents. There is a complaints procedure in the home and the manager investigates complaints within 28 days. Written reports showed that concerns raised by one relative about the care of a resident had been looked into and resolved by the manager. Residents told the inspector that they felt able to raise any concerns with the manager or with staff. Out of eight comment cards received, seven people commented that they knew how to make a complaint. Holmes House Care Home DS0000058967.V318348.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): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a comfortable living environment. EVIDENCE: During the visit, the inspector looked around at some parts of the home. A sample of bedrooms, bathrooms and toilets were checked. We found all areas were clean and tidy. Residents are able to have their own possessions in their bedrooms, and one resident said that his son had built a bird table, which was now positioned outside his bedroom window so he could watch the birds. Residents told the inspector that they felt comfortable in the home and had what they needed in their own bedrooms. Of eight comments cards received, Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 19 three people commented that the home is always fresh and clean, and five people commented that it is usually fresh and clean. One person said that there is occasionally a smell of urine in the home, but the inspector did not notice this during the visit. Another person commented: ‘Think the home is very high standard of cleanliness and hygiene.’ The manager makes sure that safety precautions and checks are carried out in the home. There is a fire risk assessment in place. Fire safety checks are carried out but there had been some recent missed checks, which the manager explained was because they had been without a maintenance worker for a short time. There are systems in place for making sure laundry is done efficiently. Staff told the inspector about safety precautions for controlling the spread of infection, and there are procedures in the home to make sure that staff work safely. Holmes House Care Home DS0000058967.V318348.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): 27, 28, 29, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents benefit from a well trained staff team and positive recruitment processes. EVIDENCE: There are a minimum of five carers on duty during the day. Out of eight comments cards received, six people said that staff were always available when they needed them, and two people said they were usually available. One person said that staff sometimes take a bit of time to answer a buzzer. During the visit, the inspector saw that staff responded quickly to call bells. One relative commented that staff always took time to contact them if their relative had to be taken to hospital. The inspector checked a sample of staff records. These showed that staff are recruited properly, and that the manager makes sure checks are carried out so that she can be confident that staff are safe to work with residents – such as Criminal Record Bureau checks. Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 21 There is an ongoing staff training programme in the home. Staff learn a range of different skills to help them to improve their ability to care for residents in the home. Recent training courses completed by staff include care planning, protecting vulnerable adults from harm, food hygiene and fire safety. The manager has introduced new contracts for one to one supervision with staff, to make sure that staff are properly supported. Holmes House Care Home DS0000058967.V318348.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): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well managed home EVIDENCE: The manager runs the home in a positive and open way. Staff feel that they can approach the manager and be well supported. Attention is paid to making sure that the quality of service provided in the home is good. Residents are asked in various ways for their views about the running of the home: for example, through questionnaires – there was a good response rate to questionnaires, and most responses were positive about the Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 23 home. Relatives have written letters describing how staff have been supportive in looking after residents. The manager holds relatives meetings every three months. The manager carries out quality assurance checks of different aspects of the service, including spot checks. The provider of the service carries also carries out checks and prepares reports for the Commission for Social Care Inspection on a monthly basis. The manager makes sure that any money held in the home for residents is looked after properly. Staff keep records and receipts of money spent on behalf of residents. The manager and staff make sure that the home is run properly, keeping residents safe. Staff have training in safety aspects, such as food hygiene and infection control. There are procedures in place, which tell staff how to work safely. Holmes House Care Home DS0000058967.V318348.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 It is recommended that there is a clear record in medication charts about medicines, which are prescribed to be taken when needed. It is also recommended that the manager ensures that any changes to medication charts are made with appropriate safeguards, such as signatures of GPs. The manager currently carries out reporting of serious incidents affecting the welfare of residents to the Commission for Social Care Inspection and other relevant organisations, under Regulation 37, Care Homes Regulations 2001. It is recommended that the manager also reports any incidents involving aggressive behaviour by someone with dementia, which causes potential risk to others. It is recommended that the manager ensures that fire safety tests are consistently carried out at the required intervals. 2 OP18 3 OP19 Holmes House Care Home DS0000058967.V318348.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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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