CARE HOMES FOR OLDER PEOPLE
Holmwood Nursing Home Warminster Road Norton Lees Sheffield South Yorkshire S8 9BN Lead Inspector
Sue Turner Key Unannounced Inspection 25th June 2007 09:00 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 Holmwood Nursing Home DS0000021787.V319982.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. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Holmwood Nursing Home Address Warminster Road Norton Lees Sheffield South Yorkshire S8 9BN 0114 250 9588 0114 258 0911 holmwood@schealthcare.co.uk 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) Southern Cross Home Properties Limited Miss Christine Hockley Care Home 41 Category(ies) of Dementia - over 65 years of age (41) registration, with number of places Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One individual named on the Registration Variation Application Form dated 12/9/03 who is in the category OP, Older People, may reside at the home. 5th January 2006 Date of last inspection Brief Description of the Service: Holmwood is a purpose built care home, which provides care for 41 older people who have Dementia. Southern Cross Healthcare owns it. The home is in a residential area of Sheffield with good access to public services and amenities. It is a two-storey building; the first floor is accessed by a lift. It is generally well decorated with good quality furniture and furnishings provided. All bedrooms are single with en-suite facilities. A private car park is provided at the front of the property. The gardens are landscaped and have a large patio area to the rear. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was also on display in the entrance hall. The manager confirmed that the range of fees from 1st April 2007 were £446 £600 per week. Additional charges included hairdressing and private chiropody. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner and Mike O Neil regulation inspectors. This site visit took place between the hours of 9.00 am and 3:30 pm. Christine Hockley is the registered manager and was present during the site visit. The manager had submitted a pre inspection questionnaire and four people living in the home, one relative and three professionals had returned care home surveys to the CSCI prior to the actual visit to the home. Their views and some information from the questionnaires are included in the main body of the report. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to six staff and six relatives. A substantial number of people who live in the home were observed; due to their degree of dementia this was an appropriate way of taking into account their well-being. What the service does well:
Health professionals made comments such as “we’re always given a room to use and contacted promptly when people need adjustments or repairs to their spectacles”, “the staff are welcoming, helpful and friendly” and “staff seem to be concerned to provide appropriate care in a holistic way”. Two surveys returned from GP’s said “we have positive and helpful working relationships with the home”, “staff are caring and motivated to improve peoples life’s”, “there is a very good dedicated staff team with appropriate skill mix” and “the home are very receptive to ideas and suggestions to improve care”. The inspectors observed that people were well dressed in clean clothes and had received a good standard of personal care. One relative said “the staff have good taste, my husband always looks nice with matching clothes which matters a great deal as he always took such care with his appearance”. Care plans were in place. These were well set out and easy to read. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. People’s health care was monitored and access to health specialists was available. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 6 Relatives said and the inspectors observed that there was a good choice of food available and that the quality of food served was good. There was a complaints procedure and adult protection procedure in place, to promote peoples safety. Relatives said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. Relatives said that the staff and managers were all “pleasant, helpful and approachable”. One relative said that when they had raised an issue with the manager she had “responded swiftly and appropriately, in order to solve the issue”. Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and in the main carried out, and systems were checked and serviced to maintain a safe environment. What has improved since the last inspection?
Care plans seen included specific details of peoples care needs, these were written in a clear and easy to read format. They also included risk assessments that identified the action staff needed to take to protect people and ensure their health and well being. The home had a full record of all medications kept for each person. People and their relatives had been asked to complete a form, which listed their personal wishes at the time of their death. This was then retained within each persons care plan. Maintenance and redecoration work had taken place on a ‘rolling programme’. The environment was well decorated, well maintained, clean and fresh. Communal areas were enhanced with colourful and tactile displays, which helped people with dementia to interact and remember their lives, hobbies and pastimes. Baskets attached to the walls contained things that people could pick up, take and use, occupy themselves with and enjoy. The manager was finishing work on two rooms chosen as “Holmwood Tavern” and “Holmwood Sweet Shop”. Both were very authentic looking and it was believed that people would enjoy visiting and spending time in these two places. Staff were receiving formal supervision and training that helped to equip them with the skills needed to carry out their role. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 7 Regular fire drills were being undertaken to ensure that everyone was aware of their role and responsibilities in the event of a fire breaking out in the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient updated and relevant information to inform people about their rights and choices. Trial visits were encouraged to enable people to look around the home, meet other people living there and give them the information needed to make informed choices. EVIDENCE: The homes Statement of Purpose and Service User Guide were available and included useful information about the home and the services offered. Both the Statement of Purpose and Service User Guide had been updated accordingly. Each person had a contract, a copy of this was kept on each persons file. One relative said “ the contract I received was thorough and informative, written very clearly and had a useful ‘Definition of Terms’’.
Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 10 Professionals and staff from the home prior to admission taking place assessed people. This either took place at Holmwood or at peoples own homes if they preferred. The manager said that assessments in hospitals were also possible if needed. This enabled staff to be aware of individuals needs and to ensure that they could be met. A relative said “the manager was very good at answering questions and giving me information. Staff were sensitive to my feelings as choosing a nursing home for my mother was one of the hardest things I had to do”. This home does not provide intermediate care services. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, social and personal care needs were well documented in the care plans and a range of health care professionals visited the home, which meant that individual needs could be fully met. Some medication procedures did not fully protect people’s health and welfare. People and their relatives were very complimentary about the way staff cared for them and the ways they promoted their privacy and dignity. EVIDENCE: Four plans of care were checked. Care plans contained a full range of information, in a concise and easy to read format. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs
Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 12 were met. Staff were aware of the contents of care plans and were knowledgeable about peoples individual needs. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists also visited the home as requested. People and/ or their relatives were involved in drawing up and reviewing the care plans. Staff were updating risk assessments and care plans on a monthly basis. Relatives said “when I have made comments or suggestions about mums care, staff have always acted on them and I have been reassured that it’s not a problem” and “the nurses have responded to any medical queries I have had and phone me regularly about my mother if there are any concerns” and “mum has no pressure areas at present, she did have in the past and these were dealt with immediately”. Medicines were securely stored around the home in locked trolleys within cupboards. Nurses administered medication, some senior carers had also received training in medication administration, however they did not administer themselves but assisted the nurses. The majority of medications were given after meals unless otherwise instructed, this was commendable practise. Medicine Administration Records (MAR) checked were not all completed with staffs’ signatures, however medications that were not signed for had been removed from the blister packs or containers. People said that staff at the home respected privacy and dignity in a number of ways, for example, by knocking on doors and waiting for a response before entering and ensuring people remained partially covered during bathing, dressing and undressing. The inspector observed other good practise actions. Staff spoke to people in a respectful way and showed empathy and patience when providing personal care to them. Peoples preferred funeral arrangements had been discussed with either themselves or their family and friends; this information was then recorded in each care plan, which ensured that their wishes following their death could be respected. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People would benefit from an activities programme that took into consideration their specialised needs and encouraged them to exercise more choice and control over their lives. Meals served at the home offered choice that ensured people received a healthy balanced diet. People were able to maintain contact with their family and friends. EVIDENCE: The manager said that they had recently employed an activities worker who would share her time between each floor and enhance the activities programme that was presently the responsibility of the senior carers. On the day of the site visit the activities person spent time assisting the carers with tasks like feeding, the manager said this was because she was “trying to get to know people and finding her feet”. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 14 One relative said “they have fantastic entertainers that come in regularly and it’s a joy to see how much the residents enjoy this” and “they often have the radio on, but I would like to hear them play CD’s of music from the 1940’s 50’s and 60’s”. The inspectors observed that throughout the morning period most people remained in the dining room, some sat in wheelchairs or chairs at tables others stayed in recliner chairs. Many people were unable to move due to the positioning of chairs therefore restricting their freedom of movement. When people did attempt to get up and move staff coaxed them to remain seated. The inspectors observed lunch in both dining rooms. A substantial number of people were served a soft diet of cauliflower cheese, mashed potato and mixed vegetables. Relatives said “they deliver a traditional menu, which my mother enjoys” and “dad enjoys his meals and has put on weight, if we call to see him at mealtimes he’s always tucking in. The food always looks and smells delicious and there’s plenty of variety”. Many people needed assistance to eat and staff were seen sitting between two people assisting them at the same time, others had to wait until someone was available to help them. One person left the dining room without eating their lunch, staff said “she always did this” and eventually the meal was removed uneaten. Another person was asleep at the table, the inspector observed that staff were too busy to notice this and again the meal was eventually taken away uneaten. In this persons care plan there was specific reference to them “regularly falling asleep at the table” and how staff must manage this, this did not transpire on the day of the site visit. One person was assisted to be fed and then reached out for their drink, the carer moved the drink out of reach, when asked why this was the carer said they were not allowed to drink themselves as they would spill the drink. The orange juice was in a safety beaker and the person had a protective apron on, therefore any risk of harm was negligible. The inspectors spoke to the manager about the ‘overprotective nature’ of some staff, which was resulting in people’s choices and rights being compromised. The inspectors acknowledge that this was not intentional but more through a lack of foresight into the needs of people living with dementia. The inspectors saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. One relative said “we chose Holmwood on recommendation, we can drop in at any time and are always made to feel welcome”. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and staff were aware of these. People and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their family and friends had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and informed the reader of who to contact outside of the home to make a complaint should they wish to do so. Relatives said they had no concerns about the home, staff or service provided. They said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes.
Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 16 Since the last inspection the home had received three complaints, two regarding an increase in fees, one had been resolved and another which was still being investigated by the organisation. The third was a relative complaint, which was investigated by the manager and resolved to the relative’s satisfaction. CSCI had received one anonymous complaint about the home, which had been investigated by the organisation and had been resolved. Staff spoken to were clear how to respond and record any complaints received. An adult protection procedure was in place, which contained information on the Department of Health guidance `No Secrets’. Staff had undertaken formal training on adult protection, which had equipped them with the skills needed to respond appropriately to any allegations. People spoken to said that they felt safe living at the home. One relative said “ depending what my concerns are, I would speak to either the carers, nurses or the manager, they are all helpful and supportive”. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was maintained to a high standard. The environment was very clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and people’s bedrooms were well decorated and personalised. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home was clean and tidy. Lounge and dining areas were domestically furnished to a good standard.
Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 18 Since the last inspection refurbishment and redecoration of the home had continued. Carpets and furniture had been replaced and areas of the home had been redecorated. The manager had a programme of refurbishment and redecoration that ensured that the home was aesthetically pleasing and free from hazards. The manager said that the organisation would carry out any work that she deemed necessary for the comfort and well being of the people living in, working and visiting the home. Bedrooms checked were comfortable and homely. People said their beds were comfortable, bed linen checked was clean and in a good condition. No unpleasant odours were noticeable in the home. Relatives and people said that the home was always kept clean. It was important to keep the home tidy and free from any hazards due to the number of people with high dependency levels, the inspectors observed that all areas of the home were organized and uncluttered. Window restrictors were fitted to all windows checked, which assisted in maintaining peoples safety. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. One relative said “dining room chairs and wheelchairs could do with extra washing due to food debris”. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers, recruitment procedures promoted the protection of people, staff had completed training, including induction, which ensured that they had the competences to meet people’s individual needs. EVIDENCE: Staff said that there was enough staff working at the home to ensure that people’s individual needs were met. The manager confirmed that staffing levels were above the agreed minimum. The home cared for people with a high degree of dependency and the inspectors talked to the manager about the possible need to increase staffing levels. The manager said that dependency levels of people were kept under constant review, if there was a need to increase staffing levels then the manager said that this would be implemented immediately. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 20 Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Senior staff had undertaken training in medication procedures and some other specialised topics. As the majority of people living in the home had dementia all staff had also undertaken training caring for people with dementia. There were twenty one carers working at the home, of these seven had achieved their NVQ Level 2 or above, three were currently undertaking the training and four were awaiting to be enrolled on the course. Although this had improved this still fell short of the required 50 of staff to have achieved this award. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Two staff files checked identified that the member of staff had received induction training when they commenced work. The recruitment records of three employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them, these were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made and Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager’s leadership approach benefited people and staff. Quality Assurance Systems, staff supervision, relative and staff meetings meant that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. Some records were not fully completed. In the main people’s health and safety had been promoted and protected. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager was experienced in the care of older people, was hard working, competent and carried out her role to a high standard. She was committed to ensuring that people living in the home were well cared for, safe and happy. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. Monthly monitoring visits by the responsible individual took place. Records of these visits covered aspects of the home and staff said that the provider “took time out” to speak to them and ask their opinions as part of this process. The manager and provider had a number of ways in which to assess the quality of the service and make improvements. Relatives said they had recently completed questionnaires, giving their opinions of the home, these were sent out yearly and action to address any issues highlighted were being considered by the manager. Relatives also said they were invited to relative meetings; staff meetings also took place on a regular basis. Arrangements were in place for people who were unable to manage their monies due to their mental health. Monies were securely stored and people were able to access their monies for hair care and personal items as they wished. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. Staff and peoples records were securely stored. In the main peoples records that were seen on the day of the site visit had been signed and dated. The equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. Staff said fire drill training took place on a regular basis. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 23 During the site visit a number of people were seen being transferred in wheelchairs that did not have footplates fitted. This was discussed with the manager and staff were asked to put footplates in place unless there was a completed risk assessment that stated the reason why it would be more detrimental to the person if footplates were in place. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 25 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 To fully ensure the safety and well being of people MAR sheets must be fully completed at the time of medication administration. People must be helped, supported and encouraged to make choices and take control over their lives. At meal times people must be given the individual support they need to ensure they receive a healthy balanced diet. Footplates must be fitted to all wheelchairs unless there is a completed risk assessment that states otherwise. Timescale for action 25/06/07 2. OP14 12 25/06/07 3. OP15 16 25/06/07 4. OP38 13 25/06/07 Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 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. Refer to Standard OP30 Good Practice Recommendations 50 of all care staff must achieve a National Vocational Qualification (NVQ) level 2 in care. Holmwood Nursing Home DS0000021787.V319982.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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