Inspection on 25/07/06 for Holmewood Manor Care Home

This inspection was carried out on 25th July 2006.

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

Holmewood Manor Care Home 17/09/09

Holmewood Manor Care Home 05/08/08

Holmewood Manor Care Home 02/08/07

Holmewood Manor Care Home 13/03/07

Holmewood Manor Care Home 08/02/06

Holmewood Manor Care Home 19/10/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Holmewood Manor Care Home Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH Lead Inspector Sue Richards Key Unannounced Inspection 25th July 2006 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 Manor Care Home DS0000064198.V302413.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 Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmewood Manor Care Home Address Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH 01246 855678 01246 852953 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) Hallmark Healthcare (Holmewood) Ltd Mrs Vivian Gwendoline Ritchie Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: The Manor Residential Home provides personal care and support for up to 40 older persons. It is located off the main road in the village of Holmewood, which lies to the north east of Chesterfield, close to Junction 29 of the M1 motorway. The home comprises of 34 single bedrooms, 10 of which have an en suite facility and three double bedrooms, all having an en suite. Single bedrooms without en suites have wash hand basins fitted. There is a choice of lounge and dining rooms to each floor, accessible by both stairs and a shaft lift. There are also a number of environmental adaptations and equipment provided to assist those with physical disabilities. There is level access to a well-kept garden with seating provided and also car parking spaces. Activities are organised on a regular basis, and details of these can be found in the entrance hallway. Twenty-four hour staffing is provided from a team of care support and hotel services staff. The registered manager is supported with the deputy manager and external management arrangements of Hallmark Healthcare Ltd. Catering and laundry services are centralised, although there is a small laundry facility for service users who may wish to launder personal items. Fees charged are as follows: £ 289.70 (minimum) per week – to £319.70 (maximum) per week – information provided in pre-inspection questionnaire from 01/04/06. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is key inspection, where all key standards as stated in the Department of Health’s National Minimum Standards Document for Older Persons accommodated in care homes was inspected. The Inspector is assisted by the acting manager, in the absence of the registered manager. Methodology used included a review of information held by the Commission about the home over the previous 12 months, together with a pre-inspection questionnaire completed by the home and questionnaire surveys from the Commission to a random sample of 10 residents/representatives. A site visit was also undertaken to the home, which was unannounced. During this visit case tracking of three residents was undertaken. This involved the random sampling of three residents whose care and service provision was closely examined. Discussions were held with them (where able) about their care and their care and associated records examined. Discussions were also held with the manager and staff and the private and communal accommodation of those residents was inspected. What the service does well: What has improved since the last inspection? Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 6 The home’s adult protection policy and procedural guidance has been developed to provide accurate information for staff in respect of the action to be taken in the event of any suspicion or witnessing of abuse in accordance with Derbyshire’s agreed joint agency procedures. Requirements made at the previous inspection in respect of the management and administration of medicines has been achieved. 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. Holmewood Manor Care Home DS0000064198.V302413.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 Holmewood Manor Care Home DS0000064198.V302413.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Comprehensive and person centred needs assessments were recorded for each resident in accordance with a recognised model. Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: Discussions were held with three residents case tracked about their care (in accordance with their individual capacities) and also with staff. The recorded needs assessment information for each of those residents was examined, together with their daily living plans. Information recorded was comprehensive and person centred. Revised needs assessment and care-planning format had been introduced since the previous inspection. Pre-admission assessment information was also provided for each resident, including a copy of the single assessment and care plan summary for those admitted by way of care management arrangements. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents personal and health care needs were well accounted for and their health care needs were being met, however, direct consultation with them to inform their social care plans was not always best promoted. Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: The written care plans of residents case tracked were examined and discussed with them and staff. These were formulated in accordance with their individually risk assessed needs and were reflective of recognised guidance associated with the care of older persons. A discussion was held with the acting manager and also the acting Operations Director regarding the use of two differing risk assessment tools for pressure ulcer risk monitoring, which identified differing risk levels. Each of the residents had both completed in their personal file. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 10 One of the residents case tracked had specific nutritional needs identified. Recent review documentation indicated that there had been considerable discussion with this resident, including outside health care professional advice in order to review and plan this aspect of care in order to meet with the residents personal preferences as far as reasonably practicable, given their risk assessed needs. However, the care plan was not yet signed as agreed with the resident as to their specified and agreed dietary preferences and presentation format. Although consent forms were in place regarding individuals’ care plans none of these were signed by them. This was discussed with the acting manager, given the recent introduction of revised care plans under the new format. Details of residents’ access to outside health care professionals were clearly recorded, including outcomes. Care plans were formulated and/or reviewed in order to include health care practitioners advice. Feedback from residents/representatives was that they felt their health care needs were being met and were satisfied with these arrangements. The individual rooms of residents’ case tracked were inspected and these were suitably equipped in accordance with their identified health care needs. The Inspector was also advised that an outside group come into the home on a fortnightly basis in order to provide opportunities for residents to undertaken physical exercise. The complaints record detailed a complaint raised by way of care management arrangements regarding staffs’ moving and handling practises and equipment provision in respect of an identified resident. The care manager had discussed with previously with the Commission. This was discussed further during the site visit with the acting manager and details of action taken were provided and were satisfactory. The arrangements for the management and administration of medicines were examined. These were generally satisfactory, although a small number of gaps of recording for the administration of some medicines (including one prescribed cream) for two residents case tracked were observed. A number of recommendations had been made by the visiting pharmacy supplier a their last visit. These had been achieved. Staff was observed to be respectful in their approaches to residents, who overall felt that they were, although the complaints record detailed two complaints regarding identified staffs’ approaches to them. This had been resolved to the satisfaction of the complainant. There were suitable arrangements to enable residents easily access a telephone and also for the receiving and sending of mail. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 To date the arrangements for residents to participate in social, leisure and occupational activities of their choice have been good. However, the recent changes in staffing arrangements and staff deployment have at times had a negative impact on the quality and frequency of those arrangements. Residents are provided with nutritious food, in accordance with their risk assessed dietary needs. However, residents are not provided with details of the choice of menu in an open manner. Quality outcome in this area is adequate. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: Feedback from residents indicated that there were usually activities organised in the home, which they could take part in, although there had been some difficulties of late due to staff sickness. A trip to the well dressings had been planned with staff escort the previous week and community transport booked for residents who wished to go. This had been cancelled on the morning of the trip due to inadequate staffing in the home (see Staffing section of this report). On the afternoon of the inspection a singer/guitarist came into the home to entertain resident. Those who chose to attend enjoyed this. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 12 An activities co-ordinator is employed, who was on annual leave at the time of the inspection. Discussions with the acting manager and staff indicated that she had been undertaking care duties on occasions of late due to staff shortages through sickness. Examples of activities organised in the home, include board game/flower arranging, crafts and manicures. Details of some activities planned for the coming year were posted on the residents’ notice board and included various entertainments in house, the local carnival and a summer fair. One of the residents is an excellent artist and is supported to pursue her hobby both in and outside the home, including recent success in the Elderly Accommodation Council over 60s Arts Awards resulting in her work to be displayed in an exhibition in London Mall Galleries along with 122 other works out of a total of 1500 entries. Visiting to the home is open, with a number of visitors during the site visit to the home. A number of residents regularly visited their own relatives/friends in the community. There was a format for the recording of activities, including past hobbies and interests. The activities co-ordinator was also compiling life stories for each resident with their consent. Residents care plans examined did not contain detailed social care plans. Copies of food menus were provided along with the pre-inspection questionnaire. This detailed a traditional and nutritious diet, with an alternative choice detailed for each meal. Menus were not displayed at the site visit. Staff said that residents were verbally asked daily on an individual basis regarding the main meal and that if the resident did not want this an alternative was provided. Some residents spoken with also confirmed this. Feedback regarding the quality and choice of food was variable, although in the main residents felt it was usually satisfactory. One resident case tracked was provided with a soft diet at lunchtime in accordance with their risk assessed needs and enjoyed by the resident, who gave it a ‘thumbs up.’ (See also health care section of this report). Staff assisted residents at lunchtime in accordance with their assessed needs in a calm and unhurried manner and tables were set attractively, including table cloths and napkins. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is a suitable complaints procedure in place for the home and residents/representatives right to complain is upheld. There are suitable systems and procedures in place to promote the protection of residents from abuse, although not all staff was conversant with these. Quality outcome in this area is adequate. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: The home has a written complaints procedure, which is displayed, although it is not in a position where it would easily be noticed. This contains suitable information regarding how to complain. Some residents and relatives spoken with were not aware of this and had not seen the displayed procedure. The majority knew how to complain and felt they would be listened to. A record of complaints received, including action taken and outcomes is maintained in the home. This was examined. There were three complaints recorded (also referred to under the Health care section of this report). Records examined and discussions with the acting manager indicated that satisfactory action was taken in accordance with the written policies and practises of the home and that they are resolved. The company’s written policy regarding abuse awareness and procedures to follow in the event of any suspicion of or witnessing of the abuse of any resident has been reviewed since the previous inspection to include locally Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 14 agreed joint agency procedures. Copies of this were filed in individual staff personal files examined (see also staffing section of this report), of four newer staff starters. These had been signed by them as read and understood. Some staff had also received adult protection awareness training since the previous inspection, which included the home’s whistle blowing policy. However, some staff spoken with was not conversant with the revised policy/procedures. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26 Residents live in a safe and well-maintained environment, which is suitably equipped and furnished and decorated to a high standard. Quality outcome in this area is excellent. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: A total refurbishment programme has recently been completed for the home to a high standard. The private and communal accommodation of residents case tracked was inspected. All areas were clean and comfortable, suitably equipped and furnished and decorated to a high standard. Residents have access to outdoor space with seating provided. A number of residents were out in the garden and seated near the front entrance at the time of the inspection. Residents spoken with were fully satisfied with their environment, including their own bedrooms, which were personalised. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 16 Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 The home was unable to demonstrate that residents were in safe hands at all times, both in respect of staff recruitment practises and the arrangements for their induction and training and thereby did not ensure their protection. Quality outcome in this area is poor. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: Details regarding staff employed were provided by way of the pre-inspection questionnaire, with the exception of details of individual staff CRB status requested. Information was also provided by way of the questionnaire regarding staff turnover, copies of staff duty rotas from 01-21 May 2006 and staff training over the preceding 12 months, although no details were provided of training planned Staff duty rotas provided a total of four care staff throughout the day and two at night for a total of 23 residents also listed on the questionnaire at the time of completion on 15 May 2006. At the time of the inspection there were 26 residents accommodated, including 2 respite, with a further respite admission planned. The registered manager is absent from the home. Given the length of time of her absence, an acting manager has very recently been introduced into the home. Her hours are additional to the above working from 8 am to 4pm Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 18 Monday to Friday. However, since her appointment and the week before this site visit to the home, the number of care staff provided during the afternoon has been reduced to three in total from 2.30 pm to 9.00 pm. Therefore from 4.00 pm to 9.00 pm Monday to Friday there are only 3 care staff for 26 residents and at weekends only 3 care staff from 2.30 pm until 9.00 pm. The activity co-ordinator works at the home on a part time basis, although was on 2 weeks annual leave at the time of the site visit. Staff spoken with was concerned about this, although were working hard to ensure that residents needs were met. Residents spoken with largely felt their needs were being met. (See also Daily Life and Social Activities). Information regarding residents’ dependencies had not been completed on the pre-inspection questionnaire. These were discussed with the acting manager and staff at the site visit. With the exception of one resident, dependencies were low to medium. However, a re-assessment had been undertaken by way of care management arrangements for the resident with high needs and her future care determined in accordance with that. Discussions were held with the acting manager and operations manager regarding staffing levels in the home at identified times as stated above and the need to ensure that staff were provided at all times to meet the needs of residents accommodated. Arrangements for staff recruitment, induction and training were also discussed with the acting manager and staff. A total of four personal files were examined for the most recent new staff starters, whose commencement dates ranged from December 2005 to April 2006. These did not contain full information and documentation, which must be obtained prior to their employment in respect of ascertaining their fitness. All had commenced their employment before full and proper checks had been obtained in respect of their fitness. One of the four, working night duty in the home since April had no documentation provided in respect of their employment, including no fitness checks undertaken in respect of POVA and criminal records checks, no completed application form in respect of their employment and no references or details of employment history. One file had an application form completed for ‘bed maker’ in 2004. This staff member had left and returned to work at the home as a carer in December 2005. There was no application for this post and no references obtained. Their POVA check was confirmed in July 2006, with CRB check outcome awaited. Serious concerns were raised in writing during the site visit in respect of the above with the acting manager and operations manager. The operations manager assured that the above would be dealt with immediately. A letter has also been sent to the responsible individual for the Company raising these serious concerns and requesting immediate action to be taken. Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 19 All of the four staff whose files were examined had no record of induction training and development, with the exception of one staff having a copy certificate for NVQ achieved in their previous employment. Discussions were held with staff about the arrangements for their induction and training. Four out of 19 care staff have NVQ level 2 in care. There was no-one undertaking NVQ training. All with the exception of one (a more recent staff starter whose personal file was examined), had worked in the home for many years. They confirmed that they had undertaken training in moving and handling, and food hygiene and handling, infection control and health and safety, although dates were not confirmed. The acting manger advised fire training was planned and dates were provided. Information provided on the pre-inspection questionnaire detailed that four staff have first aid certificates. She also advised that a further two had recently undertaken dementia care training with three booked to go and that all staff responsible for medicines administration had received appropriate training. However, there were no clear records provided in respect of staff induction and training and staff did not have individual training plans. Holmewood Manor Care Home DS0000064198.V302413.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The home is not being effectively managed to promote residents’ health, safety and welfare. Quality outcome in this area is poor. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: The registered manager is currently absent from the home for more than 2 months. Given her extended absence an acting manager had been appointed on a temporary basis at the end of June 2006. There was no job description provided for the acting manager. There is a quality assurance policy in place for the home, which refers to provisions for the auditing of the homes care and services offered and Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 21 including the use of resident/relative and staff satisfaction questionnaires. The policy was no in operation. This was discussed with the acting Operations Manager, who advised that a formal quality assurance system was to be rolled out into the home within the next 3 months, with an aim to working towards Investors in People over the coming year. Written policy and procedural guidance was in place in respect of the management and handling of residents’ monies. Arrangements were examined in respect of this for the three residents’ case tracked, which were satisfactory and in accordance with the stated guidance. Discussions were held with the manager and staff regarding the arrangements for staff supervision. There is no formal system of individual staff supervision in operation. Discussions were also held with the acting manager and staff about the arrangements for core health and safety training for staff, including induction (See Staffing section of this report). Information was also provided in the preinspection questionnaire regarding the maintenance of equipment in the home and a number of certificates of maintenance examined. These were satisfactory with the exception of details for the hot and cold water system maintenance and testing to prevent risks from Legionella, which were not provided. Written environmental risk assessments were in place, which were up to date and the systems and arrangements for the reporting and recording of accidents and untoward occurrences were also examined and were satisfactory. Holmewood Manor Care Home DS0000064198.V302413.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 3 3 3 X 3 X 3 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 Requirement Gaps of recording must not be left in medicines administration record (Mar) charts. Staff must sign to indicate the administration of a medicine to any resident or enter the required code where this is not administered for any reason. With regard to the size of the home, the statement of purpose and number and needs of residents, it must be ensured that at all times, suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of residents. Suitable arrangements must be made to ensure that care staff has access to NVQ training. A person must not be employed to work at the care home, unless they are fit to do so and that information and documents have been obtained by the registered person in respect of that person as specified in paragraphs 1-7 of DS0000064198.V302413.R01.S.doc Timescale for action 25/08/06 2. OP27 18 31/08/06 3. OP28 18 30/09/06 4. OP29 19, 17 25/07/06 Holmewood Manor Care Home Version 5.2 Page 24 5. OP30 17, 6. OP30 18, 17 7. OP33 24 8. OP38 13 Schedule 2. (Raised as a serious concern by way of a written immediate requirement during the inspection and followed up by letter following that inspection). Records must be maintained in the home in accordance with Schedule 4(6), which must be up to date and at all times available for inspection. Persons employed to work at the care home must received training appropriate to the work they are to perform, including structured induction training & core health and safety training and records maintained in respect of that training for each staff member employed. A formal system must be established and maintained for reviewing at appropriate intervals and improving the quality of are provided at the home, which includes consultation with residents and their representatives. Details of the action taken to ensure the maintenance of the hot and cold water systems in the home, including risk of Legionella must be provided. 30/09/06 31/10/06 31/10/06 31/08/06 Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 25 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. 2. 3. Refer to Standard OP7 OP7 OP15 Good Practice Recommendations Residents should be consulted about their care plans and where possible sign their agreement to them. Residents care plans should set out in detail the action, which needs to be taken by care staff to ensure that all aspects of residents social care needs are met. Daily menus should be provided for residents (in suitable formats) and detail the full choice of menu offered about which residents should be openly consulted and enabled to make an independent choice. The complaints procedure should be displayed in a prominent position to ensure its best visibility to residents and their relatives/representatives. All staff should have an individual training and development assessment and profile. There should be a written job description provided for the acting (temporary) manager, which enables her to take responsibility for fulfilling her duties. A formal system of individual staff supervision should be established in accordance with 36.2 & 36.3 NMS Older Persons document. 4. 5. 6. 7. OP16 OP30 OP31 OP36 Holmewood Manor Care Home DS0000064198.V302413.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 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 Holmewood Manor Care Home DS0000064198.V302413.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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