Inspection on 18/10/07 for Holmewood EMI Resource Centre

This inspection was carried out on 18th October 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

Holmewood EMI Resource Centre 10/11/06

Holmewood EMI Resource Centre 09/03/06

Holmewood EMI Resource Centre 11/08/05

Holmewood EMI Resource Centre 15/03/05

Holmewood EMI Resource Centre 13/07/04

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

CARE HOMES FOR OLDER PEOPLE Holmewood EMI Resource Centre 67 Fell Lane Keighley West Yorkshire BD22 6AB Lead Inspector Mary Bentley Unannounced Inspection 18 & 22 October 2007 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 Holmewood EMI Resource Centre DS0000033522.V353566.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. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmewood EMI Resource Centre Address 67 Fell Lane Keighley West Yorkshire BD22 6AB 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) 01535 602997 01535 691095 selma.inman@bradford.gov.uk City of Bradford Metropolitan District Council Department of Social Services *** Vacant *** Care Home 32 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (30) of places Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2006 Brief Description of the Service: Holmewood Resource Centre is situated in a residential area of Keighley about one mile from the town centre. The home is on a main bus route and parking is available at the front of the property. The home is run by Bradford Social Services and provides permanent and short-term care for people with a diagnosis of dementia or a dementia type illness. The resource centre also has a day centre and an outreach service; this inspection only looked at the residential services. Accommodation is provided on two floors, in four separate units, 3 are long stay and one is for respite (short term) care. Each unit has a communal lounge/dining room, and toilet/bathroom facilities are conveniently located throughout the building. A ramp provides disabled access to the front door. The home has a passenger lift to the first floor. The home stands within its own grounds and there is a sensory garden which is easily accessible to people. In October 2007 the provider told us the weekly fees ranged from £98.60 to £435.68; hairdressing and chiropody are available at an additional cost. Copies of inspection reports are included in the Statement of Purpose, which is available on request from the home. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was done over 2 days and the first day was unannounced. Two inspectors visited the home and we spent approximately 17 hours there. The home provides care for people with dementia. Because people with dementia are not always able to tell us about their experiences, we used a formal way to observe people in this inspection. This helps us to understand what life is like for people living in the home. This is called the ‘Short Observational Framework for Inspection (SOFI). It involved us observing four people for 2 hours and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff, other people living in the home and the environment. During the visit we also spoke to staff, people living in the home, relatives and management. We looked at various records, including three people’s care plans and looked at some parts of the building. Before the inspection we sent surveys (comment cards) to relatives of people living in the home and some health and social care professionals such as GPs and social workers. We asked the home to give out surveys to staff, which they could return directly to us. Surveys give people the opportunity to tell us what they think about the service. The information we get is shared with the home but we do not identify who has provided it. We received 4 surveys from staff, none from relative or other people involved with the home. Before the inspection the home completed a self-assessment form, which they sent back to us in good time. This report includes information from the self-assessment, the surveys, our records relating to the service and our site visit. What the service does well: Our observations showed us that overall people are treated with respect and staff are aware of people’s individual strengths and weaknesses. People said the staff are “kind” and “lovely”. One person told us they are very happy with the care their relative is getting they said, “She is very well looked after”. Visitors told us they are always welcome and are offered refreshments. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 6 The home makes sure that people’s needs are assessed before they move in so that they can be sure they will be able to give them the care they need. There is space inside the home for people to walk around without too many obstacles and there is a nice garden that people can use when the weather permits. People can be confident that the staff looking after them are suitable because all the necessary checks are done before new staff start work in the home. Environmental Health has given the home a 5 star rating (the highest possible) for its standards of food hygiene and safety. What has improved since the last inspection? What they could do better: The care plans are not person centered. They do not identify people’s individual strengths, weaknesses and preferences, and therefore people may not always get the right care and support. More needs to be done to make sure that people are supported in following their personal interests and making the most of their abilities. There are not always enough staff on duty to make sure that people’s needs are met in a way that takes account of their individual preferences and abilities. The staff have not had enough training on the care of people with dementia. This means they do not all fully understand how dementia affects people and what they can do to help them. Work is needed to improve the environment to make it more ‘friendly’ and enabling for people with dementia. For example, there is no clear signposting Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 7 to help people to find their way around the home and people do not have easy access to their bedrooms. 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. Holmewood EMI Resource Centre DS0000033522.V353566.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 Holmewood EMI Resource Centre DS0000033522.V353566.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): 1 & 3. Standard 6 does not apply to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There is information available to help people decide if the home is suitable for them or their relatives. People’s needs are assessed before they move in. EVIDENCE: There is a corporate Statement of Purpose and Service User guide. This includes general information about all the homes operated by Bradford Social Services. There are additional inserts for each home giving information specific to that service. There are copies of the Statement of Purpose and Service User guide at the home but they are not readily available to people. The manager said that the way people’s needs are assessed before admission has been improved so that the home can be sure they will be able to meet people’s needs. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 10 The records we looked at showed that the home had information about people’s needs before they moved in. In most cases people who move into long-term care have already had contact with the home through the day care or respite care services. The fact that they are familiar with the setting and some of the staff usually helps people to settle in. Holmewood EMI Resource Centre DS0000033522.V353566.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): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People may not always get the right care and support because the care plans do not give a clear picture of each person’s needs and the actions that staff should take to meet these needs. EVIDENCE: We looked at care plans of 3 people living in the home. The care plans do not give a detailed picture of the person or say what type of dementia they have or how it affects them. One person told us they were worried that the staff did not always understand their relative and how the dementia had affected them. In the care plans we looked at many of the pages did not have the person’s name on and were not signed by staff. This means that care plans could easily Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 12 be lost or misfiled and there is no way of checking who has written the instructions for care. There is evidence that people, mainly family, are involved in the formal reviews that take place once a year but no evidence that people are involved in developing the plan of care. The information about how care should be given is not clear. For example in a night care plan there was no information about the person’s preferred routine for settling down such as whether they liked a drink before bed or whether they wanted the lights on or off. Nutritional risk assessments have been included in the care plans but in 2 of the 3 files we looked at they had not been completed. In one case the nutritional risk assessment showed the person was at risk but the care plan on eating and drinking did not take account of this. There was no information about how often the person should be weighed, nothing about monitoring how much the person had to eat and drink and nothing about enriching their diet. The care plans did not guide staff on how to deal with people’s behaviour. An entry in one person’s records said they are “very anxious and can be difficult to deal with” but there was no guidance for staff on what they should do. Another care plan referred to the person as “agitated and wandering” but again there was no information for staff on how to help this person. The way care is recorded is fragmented and it is very hard to get a clear picture of any one person’s care. For example there are care plans, night logs, district nurses books and GP books. This also means it is difficult to make the care records accessible to people and the use of books to record a lot of information about different people creates issues about confidentiality. Our observations showed that staff are kind and treat people with respect. However, because of the lack of guidance in the care plans and insufficient specialist training they may not always be able to give people the right care and support. Most of the staff have completed a training course on the safe management of medicines. The records we looked at were satisfactory. During our visit the medicines trolleys were left in the lounges all day. They were not secured to the wall and it was not clear why they are not put away when they are not in use. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Daily routines are flexible and there are some social activities for people. However, the approach to social care is not centred on the individual needs, preferences, and abilities of people living in the home and this means that people’s social and cultural needs may not be met. EVIDENCE: During the visit we spent two hours in the lounge on Ebor unit observing what interaction and activity staff had with a small group of people with dementia. Mostly staff spoke to people who could communicate in a warm and inclusive manner, but people who did not communicate easily were left alone for long periods of time. There was a good example of warmth and understanding from one member of staff in the afternoon when they helped to calm and reassure somebody who was very anxious. There were occasions when people were ignored because staff were busy with tasks. At times staff spoke over people talking about what needed to be done next. Many staff interactions were based on practical tasks because they Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 14 happened when lunch was being served. One of these duties involved putting ‘aprons’ on people to protect their clothing. This appeared to be routine for some people but the care plans looked at did not explain why. There were no planned activities on the day of the visit. Some people were sat looking very bored and disinterested. The main source of stimulation was the television but people were not asked what they wanted to watch. There were some books and a daily newspaper and they were given to people to look at. In Ebor lounge there were no games or ornaments that people could look at or interact with. We also spent time in the lounges on Vale and Dalton units and observed a similar picture with people relying mainly on the television for stimulation. There is a programme of planned activities but for whatever reason this is not followed all of the time. Some relatives said they were concerned about a lack of stimulation for people. The care plans do not have a lot of detail about people’s past lives and interests and there were no individual social care plans in the 3 files we looked at. Visitors are welcomed at any time and people said they are always offered refreshments. We observed lunch on 2 units, although staff said there were alternatives available we did not see anyone being offered a choice of meal. In both lounges people were sat at the table for about 20 minutes before the meal was served. There were tablecloths and cutlery but no serviettes, meaning people had to use their clothes or the tablecloth to wipe their hands. People were offered a drink with their lunch. Staff sat with people to eat but seemed to be under some pressure to get the trolleys back to the kitchen, one member of staff was rinsing off the plates while people were still eating. We were told that people could only have a cooked breakfast on Sundays. During the week the only hot option is porridge and only if people are up before 9.30am because the trolley has to be back in the kitchen by then. There is no food, such as fruit or biscuits, or drinks left out for people to help themselves to if they want a snack. One person was looking for biscuits but because staff were busy elsewhere and the biscuits are locked away she could not have any. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given information about how to raise any concerns or complaints. These are taken seriously and acted on. People are safeguarded from abuse and appropriate action is taken to follow up any allegations or suspicions of abuse. EVIDENCE: Bradford Social Services has a detailed complaints’ procedure and there is a central complaints’ officer who deals with complaints that cannot be resolved by the home. Information about the complaints procedure is displayed in the home and is included in the Statement of Purpose and Service User guide. Information provided by the home showed that they have had 5 complaints since the last inspection. At the time of the visit all the records relating to these 5 complaints could not be found and we discussed the system for recoding complaints. The records that were available showed that the home responds appropriately even to what might be seen as minor issues. All the staff have had training in the protection of vulnerable adults. The four staff that completed our surveys said they are aware of how to raise any concerns they might have. Three concerns have been referred to the Local Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 16 Authority Adult Protection unit in the last 12 months and they are still being dealt with. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is clean, tidy, and comfortable but improvements are needed to make it more suitable for people with dementia. EVIDENCE: The home was clean and tidy. The four self-contained units help to create a homely environment. However, the décor does not help people with dementia. For example, the corridor, lounge, and bedroom doors all look the same and there is no clear sign posting to help people find their way around easily. The pictures used are modern and do not attract people’s attention or promote conversation. There are no ornaments or objects for people to look at or handle. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 18 The internal layout of the home lets people walk around without coming up against too many barriers and sitting areas have been provided where space permits. People have access to a pleasant outdoor area where they can walk around or sit and enjoy the day, weather permitting. Bedroom doors are locked during the day meaning that people do not have free access to their bedrooms. Most people have some personal belongings in their bedroom but they do not really benefit from this because they are only in their rooms when they are in bed. Some people may prefer to have their bedroom doors locked but it should not be routine practice. This was discussed at the inspection last year. Two visitors commented on the inconvenience of having to find staff to get a key whenever they want to go to their relatives’ bedrooms. Since the last inspection a new boiler has been installed meaning that there are no longer any problems with the supply of hot water. Hot water temperatures are checked every month and the information is sent to the council’s estates department. The records showed the hot water temperature in one bathroom and one bedroom were in excess of the recommended safe limit on the last 3 checks, the manager was asked to follow this up. There are no bath thermometers; staff said they test the water with their elbows. This is not safe because it creates a risk of scalding. The valves that are fitted to control water temperatures can be faulty and staff should be able to check the water temperature before people get into the bath. The maintenance man is in the process of fitting hand washing facilities and paper towels to the communal bathrooms and toilets. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are enough staff to keep people safe. However, there are not always enough staff to make sure that all people’s needs are met in a way that takes account of their individual preferences and abilities. EVIDENCE: One person said “the staff are lovely here” and another said the staff are “kind”. When we visited last year the home was having problems with staffing, they were finding it difficult to recruit staff and had unusually high levels of absence. Some progress has been made and the manager is continuing to work on these issues. However, the home still has unusually high levels of absence and recruiting suitable staff continues to be difficult. The home aims to have 5 care staff and an officer on duty during the day. That gives one carer to each unit and one to help on all the units. On the day of our visit there were 4 care staff on both shifts, morning and afternoon. The rotas showed that this happens regularly. The staff who completed surveys said there are not always enough staff to meet people’s needs. The home uses Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 20 agency staff where necessary and there were a mix of agency and permanent staff on duty when we visited. There are times when staff have to go off the units leaving people unattended. For example on one unit there were no staff for over 15 minutes because of handover. Another unit was left unattended in the afternoon when the person on duty took someone out for a walk. There are no office staff in the morning. This means that the officer in charge spends most of the morning answering the phone and the door and has little or no time to get involved in care activities or the supervision of staff. No new staff have been appointed since the last inspection. The manager said a recent recruitment drive had been successful. Positions have been offered to a number of people and they will be starting work as soon as all the required checks are completed. This includes CRB (Criminal Record Bureau) and PoVA (Protection of Vulnerable Adults) checks. 75 of care staff have achieved an NVQ (National Vocational Qualification) at level 2 or above and most of the remaining staff are doing NVQ training. As well as training on the safe management of medicines and the protection of vulnerable adults staff have had training on Moving and Handling and Fire Safety. The training records are not up to date and the deputy manager has identified this as an area for action. Some staff have had training on the care of people with dementia. The staff we spoke to said it was some time since they had done any training on dementia care. Their understanding of dementia and how it affects people varied from basic to reasonable. Staff supervision and appraisals have fallen behind. This means that staff are not always getting the support they need to help them meet people’s needs. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. More needs to be done to make sure that people using the service experience good quality outcomes in all areas of care. EVIDENCE: The manager has been in post for just over 12 months and has not yet applied for registration. She said she would be sending in her application within a week of our visit. There is a corporate annual quality development plan and some of this has been implemented at Holmewood. For example, there are now regular meetings for people using the service, an external quality visitor visits the Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 22 home once a month and the home has re-established links with the local branch of the Alzheimer society. The home has not sent surveys to people involved with the service and it is over 12 months since any surveys were done. This was discussed at the last inspection and the manager is aware this needs to be dealt with. There are a lot of changes taking place in the home and there are regular staff meetings to keep staff informed about what is happening and to give them the opportunity to discuss any concerns. The home manages personal money on behalf of some of the people living there. There are suitable systems in place to make sure that people’s financial interests are safeguarded and that people can have access to their money when they want it. We found a number of shortfalls in the records, for example in care plans, complaints records, and the staff training and supervision records. Overall, the systems for managing health and safety are satisfactory. Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 2 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 3 Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 24 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 The care plans must set out in detail how people’s personal, health and social care needs will be will be addressed to make sure that people’s needs are not overlooked. Previous timescale of 23/03/07 not met. 2 OP12 16 People must be given the opportunity to take part in social activities that reflect their needs, preferences, and abilities so that they are supported in following their personal interests and maintaining their abilities. Previous timescale of 23/02/07 not met. 3 OP19 23 Improvements must be made to the environment to make sure that it is a suitable and enabling setting for people with dementia. This must include looking at • The use of signposting to help people find their way around more easily Holmewood EMI Resource Centre DS0000033522.V353566.R01.S.doc Version 5.2 Page 25 Timescale for action 07/03/08 07/03/08 07/03/08 • • The way the home is furnished and decorated How people can be enabled to have easier access to their bedrooms. 14/12/07 4 OP27 18 There must always be enough staff on duty to make sure that people’s assessed needs are met in a way that takes account of their individual preferences and abilities. Previous timescale of 23/02/07 not met. 5 OP30 18 6 OP33 24 Staff must be given the training 07/03/08 they need to help them understand and support people with dementia. Records of all training must be kept up to date and available for inspection. Surveys must be sent to people 25/01/08 using the service so that they have the opportunity to say what they think about the service and to put forward ideas for the development of the service. Previous timescale of 23/02/07 not met. 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 Copies of the Statement of Purpose and Service User guide should be readily available in the home so that people using the service, and people thinking about using the service, have easy access to information about the range DS0000033522.V353566.R01.S.doc Version 5.2 Page 26 Holmewood EMI Resource Centre of services offered. 2 OP25 To reduce the risk of scalding bath thermometers should be provided so that the water temperature can be checked before people get into the bath. 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