Inspection on 10/05/05 for Holmpark

This inspection was carried out on 10th May 2005.

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

Holmpark 26/04/07

Holmpark 18/07/06

Holmpark 19/01/06

Holmpark 02/11/04

Holmpark 24/05/04

Holmpark 14/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Holmpark 212 Hagley Road Edgbaston Birmingham B16 9PH Lead Inspector Ann Farrell Unannounced 10th May 2005 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 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. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holmpark Address 212 Hagley Road Edgbaston Birmingham B16 9PH 0121 456 3738 0121 454 4495 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust Mrs Pearl Moore Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Physical disability over 65 years of age of places (39), Dementia (39) Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommdate 39 adults over the age of 65 years who are in need of care fro reason of old age not falling within any other category (39), Physically Disability over 65 years of age (39), Dementia (39). 2. Flat 39 is to be used only for the purpose of respite care. 3. Minimum staffing levels must be maintained to at least 4 care staff at all times, during the waking day. This must be increased at peak times to meet the needs of the Service Users. 4. Care Manager hours, ancilliary and activities co-ordinator should be provided in additional to Care Staff. Date of last inspection 2nd November 2004 Brief Description of the Service: Holmpark is situated on a main road close to the Birmingham city centre and is within easy reach of public transport facilities and other amenities. The building is a listed building, which had an extension built in 1988 and is well maintained both internally and externally. There is a large mature wellmaintained garden to the rear with adequate parking to the front of the property. Holmpark provides residential accommodation to 39 residents for reason of old age and dementia. Accommodation is provided over three floors, which are accessible via a passenger lift, in 37 single flats and 1 double flat. Each flat is provided with a small kitchen area and en-suite facilities that consists of a toilet plus wash hand basin and there is also an en-suite shower in the two newly renovated flats, one of which is only used for respite care. Telephone and television points are available in each room. The home has two passenger lifts enabling residents to access all areas. There is a range of assisted bathing facilities and handling equipment for moving residents. Services include laundry and weekly cleaning of the flats. The laundry and kitchen are situated on the ground floor and all staff facilities are based on the third floor. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis over a full day commencing at 7.45am on 10th May 2005. The registered manager and deputy were present for the duration of the inspection. During the inspection process the inspector toured the home, sampled residents files and other documentation. The home was clean warm and well maintained. The lounge, dining room and corridors had recently been decorated. The managers, four members of staff and ten residents were spoken to. What the service does well: What has improved since the last inspection? There has been an improvement in the range of activities provided by the home. The home organises regular meetings with residents and they also have a group made up of relatives and visitors called “ The Friends of Holmpark” who meet regularly and discuss various activities and fund raising events. There has been an improvement in the environment with decoration of corridors and communal areas. The home has addressed some of the requirements since the last inspection i.e. staff training for dementia, adult protection procedures and there is an ongoing training programme in place. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 6 Some procedures have been reviewed and the service user guide has been updated to provide a comprehensive document. 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. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 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 standard(s) 1,3,4,5, The home provides comprehensive information to enable prospective residents to make a decision about entering the home. Although the home undertake assessments of residents they lack detail and it cannot be guaranteed that all needs will be identified and met. EVIDENCE: Since the last inspection the home has updated the service users guide/information pack providing a comprehensive document for residents entering the home. At the time of visiting the inspector spoke to a resident who had recently moved into the home and expressed satisfaction although she was not able to remember receiving an information pack. The home will need to ensure that all residents receive a service user guide. The home liaises with social workers who provide written assessments or care plans for residents who wish to enter the home. The home also invite prospective residents to the home enabling them to view the facilities, meet staff and other residents and partake in a meal. At this stage the home is also able to undertake an initial assessment to determine if they are able to meet residents needs and on inspection of records it was noted they were available in files. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 9 Following admission to the home a more comprehensive assessment is undertaken and an individual lifestyle agreement (ILA) is drawn up and there is a trial period of one month when a review is held with relatives, staff and family. At the time of visiting the inspector spoke to a resident who had recently moved into the home and expressed satisfaction although she was not able to remember receiving an information pack. The home will need to ensure that all residents receive a service user guide. On inspection of the records relating to the homes admission they lacked detail. In some cases the social workers assessment provided further information for the home to utilise, but this was not available in all cases. It was also noted that the home is registered to care for residents with dementia and yet there was no assessment of mental health needs. In order for the home to develop a comprehensive care plan and meet all resident’s needs a full assessment must be undertaken. A moving and handling assessment had been undertaken, but there was no evidence of any further risk assessments e.g. falls, the use of electrical equipment in flats, difficulty with swallowing etc. Some of the staff have undertaken training in respect of caring for people with dementia and it was stated that they are in the process of organising training for the remaining staff. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The home draws up care plans for residents, but fails to ensure that residents health care needs are met. Overall there appears to be a reactive rather than a planned approach to care. Although the monitored dosage medication system was satisfactory other areas were of a poor standard and has the potential to place residents at risk. EVIDENCE: The home draws up an individual lifestyle agreement (ILA) for each resident following admission to the home outlining how the resident’s needs are to be met by staff. On inspection of a sample of records they were found to be vague in areas, lacking in detail and all needs had not been included in the plan of care. In one there was some contradictions as it stated the resident had put on weight yet the records of weight indicated they had lost weight. When the review had been undertaken at the end of the first month issues had been raised and there was no evidence of follow up; another resident had lost weight and there was no evidence of any intervention; assessments had been updated to indicate changes but there was no indication of the date and the care plan had not been updated to reflect any changes in care. Care plans had not been reviewed monthly as outlined in the National Minimum Standards. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 11 On inspection of records it was noted that one family had contacted the G.P. with concerns and another family had requested the home to contact the G.P with concerns. Although the G.P. visited and prescribed medication/changes in treatment this demonstrates a reactive approach to care rather than a proactive approach, which had to be initiated by families. Some residents had not had a nutritional assessment undertaken on admission to the home or been weighed. On inspection of daily records it was noted that an inappropriate remark had been made in one file, a record of medication sent with one resident to hospital was inaccurate and the fluid and food charts for another resident had not been completed for one full day and other days indicated very little had been given to them as they required help with feeding. Staff liaises with health professionals from the multidisciplinary team such as district nurses, social workers, CPN’s and continence adviser. On discussion with residents they confirmed that they receive visits from the chiropodist, dentist and optician on a regular basis. The home uses a monitored dose medication system and is in the process of changing suppliers. On inspection of the medication it was noted that the monitored dosage system was satisfactory, but some audits of boxed medication indicated errors. In addition, the date of a change in medication dosage had not been recorded and there was no specimen signature chart available. The record of controlled medication was poor as full details of some amounts entering the home had not been recorded, details of disposal of the controlled medication were not clear, the administration of the controlled medication had not been recorded on the MAR chart and there was a discrepancy in the amount of medication carried forward from one page to another resulting in an amount of medication not accounted for. Also there was no risk assessment for some residents who were self-administering medication even though some were known not to be taking medication properly. The home had no record to indicate that the G.P. had been made aware of these residents. This was very concerning, as it was stated that all staff had undertaken medication training. The home will need to take immediate action to ensure issues in respect of non-administration or incorrect administration of medication and poor handling of controlled medication does not occur again. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 12 On discussion with resident’s they stated they were happy living in the home, found the staff very good. One stated that they would like more frequent baths and call bells were not always responded to promptly and this was attributed to staff being busy. Residents stated they had keys to their doors and there were lockable facilities in flats. They are able to have a telephone installed in their flat if they wish and a telephone is available on the ground floor of the home for general use. During inspection it was noted that residents privacy was respected and staff treated them with dignity. Staff knock doors before entering residents flats and post is delivered to individual flats. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Meals were well managed providing a varied diet with choice and meals are of a good standard. There has been a marked improvement in the social activities available in the home providing interest for people living there. EVIDENCE: The home employs an activities co-ordinator and significant developments have been made in this area. At the time of visiting the home had just celebrated V.E day with a barbeque. The home has a karaoke machine, television, video and DVD in the lounge and bingo sessions. Progressive mobility visits the home each month and there is a range of videos, DVD’s quizzes and games available. The activities co-ordinator has recently commenced craft sessions and on discussion with some residents they stated they enjoyed them. It was stated they are hoping to organise a fete in July. There is a group called Friends of Holmpark who meet and discuss events and fund raising activities. The hairdresser visits the home on a regular basis. Ministers of various religions visit the home at residents request. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 14 Visiting is fairly flexible and residents have a choice of areas to receive visitors, which they are informed about in the service users guide. On discussion with residents and staff it was stated that they are able to make choices about the times for getting up/going to bed, meals and how to spend their time. Residents take their own furniture into the home enabling them to create a home from home environment and can handle their own finances if they wish although assistance is available in the home. The home employs separate catering staff who provide three full meals per day, which includes a three-course lunch. On discussion with residents they stated they enjoyed the meals, received a choice and ample portions. It was stated snacks and drinks are available between meals including supper if they want. The home is to introduce a new system for meals enabling residents to order their choice on the day when they enter the dining room. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents were happy and had no complaints, but felt confident that any concerns would be addressed. Residents are protected from abuse by the homes procedures. EVIDENCE: The home has a complaints procedure displayed on the notice board and is available in the service user guide. On discussion with residents they stated they had no complaints, but if they did have concerns they would go to the office. At the time of inspection the managers stated they had two complaints and they had recorded them and taken action. Records of staff training indicated that staff had received training in respect of vulnerable adults procedures. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26 The standard of décor and furnishings in the home is good providing residents with a pleasant and homely environment to live. EVIDENCE: Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 17 The home is a listed building that was refurbished and extended to provide and home that is suitable for its stated purpose. The home was warm, clean, odour free and well maintained. There is limited parking to the front with an attractive well maintained garden to the rear of the building. Access can be gained by the lounge and dining room and there is a pleasant patio area with seating, which can be used when the weather permits. Towards the end of the garden is a pond and it was stated that it had been drained and would be filled in. At the time of inspection it appeared to have filled up again and was covered with a layer of leaves. Although the pond has fencing around it is still easily accessible. There is one lounge and adjoining dining room on the ground floor, which has recently decorated and all furnishings are domestic in character. One lady stated she found the room very comfortable. Following a recent customer satisfaction survey consideration is being given to the provision of a more stimulating lounge area. All flats are provided with locks and letterboxes to doors; they are carpeted and generally service users provide all their own furnishings, although furniture is available if required. All flats are singly occupied and meet the minimum size requirements. Each flat has an en-suite facility consisting of a toilet and wash hand basin plus a small kitchen area, which has a fridge. Samples of rooms were inspected and were found to be decorated to a good standard, comfortable and personalised. Staff have a master key in the event of an emergency. Doors have appropriate locks and lockable facilities are available in flats for residents to store valuables or medication. There are two assisted bathrooms and three showers in the home, but some to not provide a call ball accessible to the washing and toilet facility. Flats are individually and naturally ventilated and windows are provided with restrainers. All areas are centrally heated and radiators can be switched on and off. However, this does not enable service users to adjust the temperature in their flats if they wish. This is an issue that has been highlighted at previous inspections and the homes action plan states the radiators can be turned on and off. Laundry facilities were sited on the ground floor and contains washing machine with sluice cycle. Part of the laundry area is segregated to provide sluice facilities and during the inspection it was noted that the laundry was left unlocked and unattended. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29. There were times when minimum staffing levels were not maintained, which will impact on the level of care given to residents and may mean there are times when resident’s needs were not being fully met. EVIDENCE: The staffing rotas indicated that the manager and assistant manager are on duty between Monday and Friday. All shifts during the day are covered by a senior carer/acting senior carer and care staff. On examination of the rotas it was noted that that minimum staffing levels of four care staff plus additional at peak times was not being maintained. There are times in the middle of the day when there is only one senior carer with one or two carers, on the evening shift there is usually a senior carer and three carers, but on occasions there is only a senior carer and two carers on duty. The home must ensure that staffing levels are maintained at all times to meet resident’s needs. At the time of inspection the managers were conducting interviews for new care and domestic staff. It was stated that there had been five new staff since the time of the last inspection and that improvements were needed in respect of recruitment and retention of staff. A small sample of staff files were inspected and found to be satisfactory. The home has an ongoing training programme. Currently eight staff have completed NVQ level 2. All senior staff have completed a first aid course and medication training. The home has also organised training in respect of dining with dignity and continence. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,38 There is a stable management team, which contributes to the efficient running of the home. Health, safety and welfare of residents needs to be further promoted and protected by ensuring that staff receive up to date health and safety and fire training. EVIDENCE: The registered manager has been in post for a number of years and has been undertaking the registered managers award. On discussion with residents they stated there were regular meetings held in the home. Staff stated meetings occurred approximately every two months and minutes were available in the staff room for those who did not attend. A sample of records was inspected in relation to maintenance and they were found to be of a good standard. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 20 Staff training is ongoing and some staff are currently undertaking infection control training plus back care training has been planned for staff. Basic food hygiene, health and safety and fire training need to be updated as on discussion with some members of staff they staff they had not undertaken fire training or drill. The home has a quality assurance system in place and recently a company has been involved in a customer satisfaction survey obtaining feed back from residents and relatives. The report from this provided positive feedback and the home scored above the mean for 30 out of the 37 attributes measured. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 2 x 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x x 2 Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 22 no Are there any outstanding requirements from the last inspection? 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. 2. Standard 1 1 Regulation 5 4 Requirement Timescale for action 20/6/05 3. 3 14 The registered person must ensure that all residents receive a servcie user guide. The registered person must 20/7/05 review and enhance the statement of purpose to cover all areas outlined in the regulations and provide a copy to the Commission. This was not assessed and has been carried forward from previous insepction. 20/8/05 The registered person must; Review the assessment procedure and ensure a competent person undertakes an assessment for all service users before they enter the home to determine if the home is able to meet needs. Following admission a comprehensive assessment must be in place with risks assessments to enable a full care plan to be drawn up. Where anyone is admitted with dementia/mental health problems a mental health assessment must be undertaken. The assessment must be updated where there is any E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Holmpark Page 23 4. 7 15 5. 12(1) 13(1) 8 6. 12(1) 13(1) 8 7. 12(1) 8 8. 13(2) 9 significant change in service users condition and dated. Timescale of July 2003 not met. The registered person must ensure; -Individual lifestyle agreements clearly cover all areas of need/risk. - They should set out in detail the action required by staff to meet all service users needs and risks. -Care plans must indicate any specific interventions/care for service users who suffer with dementia. - The registered person must ensure plans are reviewed monthly and are updated where there are any changes. Timescale of July 2003 not met. The registered person must implement a system for monitoring of service users psychological health and chronic diseases such as diabetes, asthma etc. Timescale of November 2004 not met. The registered person must ensure a nutritional assesment is undertaken on all resdients and they are weighed regularly. Where there is any significant weight loss appropraite action should be taken. Timescale of July 2003 not met. The registered person must undertake a review of current practices in the home to ensure a more pro active approach to meeting residents health care needs. The registered person must ensure; -The correct administration and recording of medication and that residents take medication when administered. Timescale of July E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc 30/8/05 30/6/05 30/5/05 30/5/05 25/5/05 Holmpark Version 1.30 Page 24 9. 13(4) 19 10. 16(2)(j) 19 11. 12. 16(2)(j) 13(4) 19 19 13. 23(4)(a) 19 2003 not met. - Accurate recording and administration of all controlled medication. Timesclae of July 2003 not met. - All medication is labelled with residents details. -The medication details are checked with the G.P. or hospital when residents are admitted to the home. -A risk assessment for all residents who are self administering any medciation is undertaken and ensure it is monitored on a regular basis. Where it is not being taken medical advise should be sought. Jan 2004 not met. -The date of any change in dose of medciation is recorded. Timscale of Jan 2004 not met. -A specimen signature chart is available. -The administration of all creams is recorded. Timescale of Nov 2004 not met. -The minimum and maximum temperature of the drug fridge is recorded. Timescale of Nov 2004 not met. The registered peson must ensure the pond area is safe at all times. Timescale of May 2004 not met. The registered person must ensure the kitchen and Bain Marie are cleaned on a regular basis. The registered person must ensure the dishwasher is repaired or replaced. The registered person must ensue the laundry door is kept locked when not attended by a of staff. The registered person must remove all flamable items from E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc 30/5/05 30/5/05 30/5/05 20/5/05 20/5/05 Page 25 Holmpark Version 1.30 under the stair case. 14. 23(2)(n) 21 The registered person must ensure there is a call bell accessible to all bathing and toilet facilities in bathrooms/shower rooms. Timescale of May 2004 not met.. The registered person must ensure staffing levels are maintained in order to meet the conditions of registration. Timescale of July 2003 not met The registered person must ensue that 50 of care staff are trained to NVQ level 2. The registered person must ensure all staff undertake training in respect of basic food hygiene and records are retained in the home. Timescale of Jan 2004 not met. The registered person must ensure that all staff undertake training in respect of health and safety to include first aid. Timesclae of Jan 2004 not met.. The registered person must ensure that all staff undertake training in respect of fire prevention and at least two fire drills each year and records are retained in the home. Timescale of July 2003 not met. The registered person must ensue that all staff undertake training in respect of tissue viability. Timescale of Nov 2004 not met. The registered person must ensure that all residents are consulted as to how often they would like a bath and ensure systems are implemented to enable their wishes to be met. 30/9/05 15. 18(1) 27 20/5/05 16. 17. 18(1) 16(2)(j) 29 38 30/9/05 30/7/05 18. 13(4) 38 30/6/05 19. 23(4)(d)(e) 38 15/6/05 20. 18(1) 12(1) 8 30/9/05 21. 12(2)(3( 8 30/5/05 Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 26 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. Refer to Standard 12 20 Good Practice Recommendations It is recommended that consideration it given to activitiies for residents with dementia. It is recommended that consideration is given to the provision of another sitting area. Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor,Ladywood House 45-56 Stephenson Street Birmingham, B2 4UZ 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 Holmpark E54_ S16908_Holmpark_ V22583_ 100505 Stage 4.doc Version 1.30 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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