Inspection on 21/04/06 for Holmhurst Care Home

This inspection was carried out on 21st April 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmhurst Care Home 12/09/07

Holmhurst Care Home 18/10/05

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

CARE HOME ADULTS 18-65 Holmhurst Care Home 28 Gordon Avenue Portswood Southampton Hampshire SO14 6WD Lead Inspector Annie Kentfield Unannounced Inspection 21st April 2006 10:30 Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 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 Holmhurst Care Home DS0000062744.V288971.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 Adults 18-65. 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. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmhurst Care Home Address 28 Gordon Avenue Portswood Southampton Hampshire SO14 6WD 023 8034 8403 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) Mrs Susan Boyes Mrs Susan Boyes Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users are not to be accommodated below the age of 30 years Date of last inspection 18th October 2005 Brief Description of the Service: Holmhurst Care Home is a large family home, extended to provide accommodation for 20 service users. Accommodation is provided in a range of single and shared rooms on the ground and first floors. Communal space comprises a lounge and small dining room. The home is registered to accommodate service users aged 30 to 65 with mental health needs. The home is located in a quiet side street a few minutes walk from the centre of Portswood and is close to local amenities and public transport. The home has recently undergone a change of owner and manager. The new owner Mrs Susan Boyes is also responsible for the day-to-day management of the home. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the home took place over one day between 10.30 am and 5.00 pm. The inspection visit followed up requirements from the inspection of 18 October 2005 and a subsequent inspection visit of 6 January 2006 and also looked at all of the key National Minimum Care Standards. Evidence for this report was gained from an inspection of some of the home’s records, a tour of the premises, and discussion with residents, staff and the registered manager. Following the inspection visit, two care managers from different community teams were contacted by telephone to gain feedback about the service provided. Comment cards were sent to the home for service users and visitors to complete and return if they wished to, none had been returned before this report was written. All comments received from service users, care staff and care managers was very positive about the home and the improvements that have been made since Mrs Boyes took over the home. Although there have been many improvements made to the way that the home is managed, the inspection found that not all of the requirements have been met from the previous inspection. New timescales have been given to address these requirements and the manager/owner has been advised that failure to meet the requirements within the agreed timescales will result in the Commission taking enforcement action. Failure to comply with the requirements of the Care Homes Regulations 2001 has the potential to put the health safety and welfare of the service users and staff at risk. What the service does well: The new manager is keen to improve standards in the home and since taking over the service in 2005 has been actively making changes to the home environment and the way that the home is managed. The home environment has improved for the service users and further improvements are planned. Residents were asked to comment about their experience of living in the home and comments received during the inspection visit demonstrated that residents have a greater opportunity to take part in activities and have more choice regarding food and the daily routines of living in the home. Some residents particularly enjoyed the holiday that was arranged last year and are keen to do this again. Comments from social care professionals were very positive about the changes that had been made to the home’s environment and say that the management approach of the home is positive and beneficial to the service users. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Since the last inspection two new residents have moved into the home. The manager has completed an assessment of care needs for these residents but only one assessment could be found at the time of the inspection. The manager has not yet updated and renewed residents’ contracts/terms and conditions. EVIDENCE: The home currently accommodates 17 residents and the manager plans to keep some bedrooms empty in order to continue with the programme of decoration and refurbishment of the home. The manager is also aware of the need to ensure that the home only admits new residents whose care needs can be met by the home. Two residents have moved into the home since the last inspection and the manager has undertaken an assessment of their care needs. However, although it is clear that the manager is in the process of reviewing and updating systems for recording plans of care, the present system is unorganised resulting in only one assessment being available for inspection. The manager also needs to ensure that all relevant information about prospective residents and their care needs is obtained from health and social care professionals before the resident moves into the home. This information Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 9 had not been provided and it is necessary for the home to have all relevant information to make sure that all care needs can be met by the home. The previous requirement to update residents’ contracts/terms and conditions has not been met within the agreed timescale of 18/11/05. This information must be available to residents and the manager has agreed that this will be in place by 30/05/06. In discussion, the manager explained that she had obtained some sample contracts but had not had time to draft a new contract and issue copies to all of the residents. The manager was advised that she must meet regulatory requirements within the agreed timescales. Although the manager has made a lot of very positive changes to the way that the home is run, priority must be given to those requirements that ensure the rights and independence of the service users. In discussion, the manager was advised that details of what needs to be included in the contract are set out in Standard 5 of the National Minimum Care Standards for younger adults. Information needs to be in a format appropriate to the needs of the service users or discussed with the service user, with family, friends or an advocate. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The opportunity for service users to make decisions for themselves is improving although this is difficult to fully assess from the home’s records, because the review of the care plans and associated risk assessments has not been completed within the agreed timescales. Some of the staff have completed training in key working and this is still to be developed as a system in the home. Confidentiality of information is much improved. EVIDENCE: The manager has acquired a new file system for individual care plans but this has yet to be put into practice. At the moment the care files are not easily accessible and need to be organised to demonstrate clearly that all care needs are identified, recorded and met, and that risks are identified and a plan to minimise risk is in place. Care plans should also demonstrate that they have been drawn up and agreed and signed, where possible, by the service user and Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 11 others involved in their care, and regularly reviewed. This was a requirement from the previous inspection and has not been met within the agreed timescale of 18/11/05 Feedback from two care managers demonstrated that the manager and staff are very aware of service users’ care needs, and there is good communication between the manager and staff and the community mental health services about the care needs of individual service users. In response to the requirement of the last inspection the manager has taken action to improve confidentiality. Details of personal care activities have been removed from the notice board and daily care records are now on separate sheets to ensure confidentiality. A checklist for service users has been drawn up and individually agreed and signed as to whom information may be shared with and in what circumstances. Programmes of daily activities could be displayed in the staff office, as this is information to prompt staff only. The manager has introduced the opportunity for service users to have regular meetings in the home and this is seen as a very positive step and one that needs to be developed so that service users are regularly consulted on and participate in, all aspects of life in the home. Work is in progress in developing a Key Worker system and some staff have already done some training and more is planned for June and July of this year in care planning and risk assessment. One member of staff said that it is planned to discuss this with the service users who will be involved in choosing their key worker. This will be a positive move towards a person centred care planning system for individual service users. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The opportunities for service users to take part in activities of their choice has improved with the appointment of an activities co-ordinator and a more structured approach to choices of appropriate activities. Service users said they enjoyed the food offered and confirmed that they can help themselves to drinks and snacks during the day or night. EVIDENCE: Since the last inspection the manager has taken action on the recommendation to convert a small upstairs room into a private sitting area for residents and this is now decorated and furnished with a sofa and coffee table. At the previous inspection some residents said that the kitchen was locked at night because night staff were asleep rather than staying awake. On this visit, residents confirmed that they can access the kitchen at night and steps have Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 13 been taken by the manager to regularly check on this. A cool milk vending machine has been installed in the kitchen and residents are able to help themselves at any time to drinks and snacks. Service users said that they are happy with the choices of menu provided. Some of the residents were out during the visit and are involved in a number of activities such as voluntary work or social activities, and some of the residents spend a considerable amount of the day without being occupied although this is partly through choice or possibly habit. However, since the appointment of an activities co-ordinator on two days per week, some of the residents have enjoyed going out to shop, or on outings of their choice, and it is hoped that there will be another opportunity for a holiday later in the year. Two care managers said that the home provides “positive support for the service users” and there is now a realistic and structured approach from the manager and staff with regard to activities and report that service users are “very happy with the changes”. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is meeting service users’ physical and emotional health needs and service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Some service users were spoken to privately and some in general conversation and the overall view was that the daily routines in the home are informal and relaxed. Service users said that they were free to choose when they get up and go to bed and said that staff would go with them to health appointments if needed. Two care managers said that they were happy that the manager and staff provide appropriate support and prompting with personal and health care and the manager and staff are very aware of the service users health and emotional care needs and know the service users very well. They were also happy that service users have access to health services as needed. Service users spoken to said that they always receive their medication as prescribed. The manager confirmed that she has arranged for medication to be regularly reviewed and has asked a local pharmacist to visit regularly to advise on Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 15 medication procedures. Seven members of staff have completed a 12-week training course in the safe handling of medication and further training for other staff is planned. The home now has a dedicated fridge for medication storage and all medication is safely stored in a locked room. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Although there have been positive improvements in this area, the recruitment procedures are not thorough enough to ensure that the service users are protected. The home has not yet provided service users with a new contract and copy of the complaints procedure. However, service users spoken to said that they would speak to the manager if they had any concerns or complaints. EVIDENCE: The manager has introduced opportunities for service users to express their views about living in the home, a residents’ newsletter and residents’ meetings, and these are very positive developments. The manager also plans to produce a handbook of the home’s policies and procedures for residents’ information. Staff morale and practice has improved with a programme of training and development and some of the staff have now completed training in adult protection awareness. The manager must ensure that service users are protected by robust and thorough recruitment procedures and this requirement has not been met from the last inspection. Service users need to have a copy of their contract/terms and conditions and written information about the home’s complaints procedures. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. This judgement is made on the basis that the home environment has improved greatly and further improvements are planned to make the home safe comfortable and homely for the service users. EVIDENCE: Since taking over the home, the manager has made many improvements to the home, implementing a programme of redecoration and refurbishment. Many comments were received from service users, staff and care managers about the positive benefits to the home environment. Further refurbishment is planned and records show that since the last inspection much has been done to improve the fabric of the building. Particularly satisfying to the service users has been the decoration of some of the bedrooms and choice of soft furnishings, and increased privacy in some of the shared bedrooms. One bedroom has been fitted with a new en-suite bathroom and one of the downstairs bedrooms has had a new shower en-suite fitted. Five bedrooms have new sets of bedroom furniture chosen in consultation with the service Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 18 users. Appliances to neutralise cigarette smoke have been fitted in the communal areas. The home was clean and tidy and warmly heated at the time of the inspection visit. Staff said that they have had training in infection control procedures. Empty rooms are being redecorated before new service users are admitted to the home. There is still scope for further improvement to the home environment and in discussion the manager confirmed that she has plans to achieve this in the long term. It is hoped that new arrangements for the living room and dining room can be made to allow sufficient space for all of the service users to eat in the dining room and for there to be a separate smoking and non-smoking lounge. The manager would also like to arrange some outside garden/seating area for residents as the present arrangements mean that all of the garden area is used for the driveway and parking. Some of the residents have storage space for bikes etc. in the garden. Since the last inspection the manager has made the small staff room upstairs into a private sitting area for residents. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The manager has developed much greater opportunities for staff training and development, and developed and introduced a new staffing structure that has positive benefits for both service users and staff. Staff recruitment procedures must be more robust and thorough to ensure that service users are safeguarded. EVIDENCE: The manager has introduced a new staffing structure that encourages better individual and team responsibility with corresponding rewards and opportunities for promotion. Alongside this there is a staff training and development programme that covers all aspects of the skills and knowledge relevant to their work. Staff spoken to were positive about the changes in the way that the home is run and liked the fact that their work was more structured and they were clear about what they had to do. Staff were feeling more confident as a result of the training they had done and felt happy and well supported and also felt that the service users were happier. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 20 These comments were also reflected in the feedback from service users and care managers. The home employs a cleaner on 3 days per week and a cook at weekends. The manager hopes to employ a weekday cook and at the moment meals are being prepared during the week by the care staff. The home also has an activities co-ordinator on two days per week and records show that outings have been arranged to shop or visit places that service users choose. Outings are taken in the home’s own transport. Further improvement is needed to the home’s recruitment procedures and the manager must make herself aware of the regulatory requirements with regard to satisfactory checks being in place before staff start working in the home. New staff may only start working in the home under supervision and awaiting a satisfactory Criminal Record Bureau check, if a check has already been done on the Protection of Vulnerable Adults List and satisfactory written references and full employment history are in place. Guidance for service providers on criminal record checks and protection of vulnerable adults checks is available on the Commission website. www.csci.org.uk Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 and 42 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The manager has a positive and energetic approach to managing the home and this was acknowledged in feedback from service users, staff and community care managers. The standard of record keeping needs to be improved to ensure that the home is fully protecting service users and also to evidence the improved level of care and support that the home provides to the service users. EVIDENCE: The manager has completed training in community mental health care and is currently enrolled to achieve the NVQ level 4 in care and the NQQ level 4 registered manager award. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 22 It was evident from observation during the visit and from comments from service users, staff and care managers that the manager is liked and respected and her positive and flexible approach to managing the home has benefits for both service users and staff. The manager is aware that the home environment could still be improved and has long term plans to meet this. In discussion, the manager is aware that record keeping could be improved and is looking at ways of delegating some of the work needed to improve care planning, and has already provided training for some of the care staff in developing a key worker system that will provide opportunity to develop a more person centred approach to planning individual care with the involvement of the service users. The manager is aware that she needs to prioritise the review of care plans and renew contracts. It is evident that service users are well supported in their day to day living activities and health and emotional care, and this needs to be backed up with clear written evidence to ensure that all care needs are clearly identified, recorded and met and that care plans are regularly reviewed with the individual service users. Recruitment procedures and records must be more thorough to meet regulatory requirements and ensure the safety of the service users. Mostly service users manage their own finances and the manager provides some support to those service users as needed. Records are kept and the manager asks service users to sign their consent to monies being collected and looked after on their behalf. The manager is in the process of developing a quality assurance system based on regular questionnaires and residents’ meetings providing an opportunity for service users to express their views about the service. This is a developmental process and service users need to gain confidence in expressing their views and knowing they will be listened to. The manager has met the previous requirements to ensure that all serious incidents in the home are reported to the Commission for Social Care Inspection under Regulation 37 of the Care Homes Regulations 2001, and also to ensure that fire detection and fire fighting equipment is regularly tested. Holmhurst Care Home DS0000062744.V288971.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 Adults 18-65 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 X 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 3 1 3 3 3 3 1 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 2 43 3 3 3 X 2 2 X Holmhurst Care Home DS0000062744.V288971.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 YA2 Regulation 14 Requirement New service users must only be admitted to the home following an assessment of their care needs and in consultation with the service user and include all care assessments carried out by care professionals involved in their care. All service users must have either a contract or terms and conditions. This was a requirement from the previous inspection of 18/11/05. All care plans and associated risk assessments are to be reviewed and updated. This was a requirement from the previous inspection of 18/11/05. Timescale for action 21/04/06 2. YA5 5(1) (c) 30/05/06 3. YA9YA6 15 30/05/06 4. YA42 YA34 YA23 13(6) 19(1)(b) Schedule 2 Recruitment procedures must 21/04/06 ensure satisfactory checks are in place and satisfactory written references received, before staff start working in the home to ensure that the service users are safeguarded at all times. DS0000062744.V288971.R01.S.doc Version 5.2 Page 25 Holmhurst Care Home 5. YA41 17 This was a requirement from the previous inspection of 18/11/05. All records required by 21/04/06 regulation for the protection of the service users such as care assessment records, care plans, recruitment records, must be maintained and kept up to date. 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 YA25YA24 Good Practice Recommendations It is recommended that the manager could produce an improvement plan for the next twelve months setting out the priorities and long term plans for the refurbishment of the home environment. Holmhurst Care Home DS0000062744.V288971.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Holmhurst Care Home DS0000062744.V288971.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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