Inspection on 27/06/08 for Holway House

This inspection was carried out on 27th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Holway House 130 Station Road Ilminster Somerset TA19 9PW Lead Inspector Gail Richardson Unannounced Inspection 27th June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holway House DS0000070933.V364730.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. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holway House Address 130 Station Road Ilminster Somerset TA19 9PW 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) 01460 53781 holwayhouse@btconnect.com Crown Nursing & Residential Homes Ltd Ms Jane Ngorima Care Home 7 Category(ies) of Old age, not falling within any other category registration, with number (7) of places Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 7. 05/12/06 Date of last inspection Brief Description of the Service: Holway House is large property situated in the outskirts of Ilminster. The home has been decorated and furnished to a good standard, and is close to local amenities. Holway House has been registered as a care home since 1990. Mrs Jane Ngorima has been the proprietor and registered manager since December 2007. Holway House is registered with the Commission for Social Care Inspection to provide accommodation for up to seven service users who require assistance with personal care. Holway House has been adapted to provide a comfortable and homely environment for service users with low to medium dependency needs. The current range of fees is from £368.00 to £470.00, this does not include newspapers, some toiletries and alcohol. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection, which took place over 1 day ( 5.5hours) on the 27th June 2008 by Regulation Inspector Gail Richardson . A tour of the home took place and all of the bedrooms and communal areas were seen. There were 3 people currently residing at the home all receiving personal care. One of those residents is receiving long term respite care at the time of inspection. Since the Commissions last key inspection the home has changed ownership. Since taking over as provider /manager in December 2007 Mrs Ngorima has experienced some difficulties in accessing information and facilities. Mrs Ngorima has experienced some difficulties in accessing information and facilities and as a result has had to re write the homes policies, procedures, and documentation relating to health and safety.’ Mrs Ngorima has liaised closely with the Commission during this period and has demonstrated her commitment to improving the quality of the service provided. The inspector spoke to 3 people using the service and 2 members of staff, the Registered Manager was available throughout the inspection. The home has provided CSCI with a completed AQAA (Annual Quality Assurance Audit) which was completed by the Manager and gives details of all aspects of the home. As part of this inspection the inspector surveyed the opinions of a random selection of people using the service and their representatives, GP’s, District Nurses and Care Workers. Surveys were sent to people using the service and reasonable levels of responses were received. The inspector spent time talking to people within the home and staff and observed that on the day of inspection, residents appeared comfortable in all areas of the home. It was evident from this observation that the people looked well cared for. Records relating to care including 2 care plans, 3 staff files and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 6 for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: What has improved since the last inspection? There has been a change in care plan management with the implementation of a new care plan system to include risk assessment and regular reviews. The home has implemented the use of a separate dining area to increase space available and the homily feeling aimed for. The home has improved infection control procedures by providing in each bedroom hand wash and paper towel facilities. Each person using the service now has individual laundry bags to reduce any risk of cross contamination and clear cleaning systems are in place to ensure a good standard of hygiene at the home. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 7 The call bell system at the home has been repaired and now enables all people using the service to call for help as needed. What they could do better: The manager must ensure that all areas of identified need have a care plan in place to ensure that staff are aware of all care needs. This will provide staff with the information they need to ensure all needs can be addressed. It is also recommended that a daily record is maintained for each person. The registered manager is required to ensure that all medications are signed as received and the quantity received recorded. This is required to ensure a clear audit trail of medications received and administered and prevent any risk of mismanagement of medications. 2 prescribed creams were noted not to have been dated when opened. This is recommended to ensure that creams are not used after the date of expiry. The registered manager is recommended to review the recording of activities to ensure development of a person centred approach to activity provision. This will support people using the service to enjoy activities of their preference and choice. The registered manager is required to review the homes policy for abuse awareness to ensure that the procedures reflect the Safeguarding Vulnerable Adults Protocol for Somerset (May 2007). This is to ensure that staff are aware of the correct procurers to follow and ensure the safety of people using the service. The registered manager Mrs Ngorima is required to ensure that all staff, including staff currently working at the home complete a full recruitment procedure to ensure that a clear audit trail is in place and there is no risk to people using the service. The manager is recommended to review some areas of health and safety which include, to risk assess the upstairs bathroom window to ensure there is no risk of accidents to people using the service. The home must ensure that all substances hazardous to health are stored securely in line with the COSHH guidance and to record the monthly hot water checks to ensure the safety of people using the service Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 8 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. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 9 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 Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to provide prospective people using the service and relatives with sufficient information in the format of the Service User Guide and Statement of Purpose for them to make an informed decision about the home. All prospective residents receive a pre admission assessment by the registered manager to ensure the home can meet the assessed needs identified. EVIDENCE: The home has in place a Service User Guide and Statement of Purpose to enable prospective people using the service and their relatives/representatives to make an informed decision about the home. The manager confirmed that people are able to visit the home and spend time there before they make a decision on residency. Short term respite care is available. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 11 The homes AQAA (Annual Quality Assurance Audit ) states that in the last 6 months the new provider has; We have completed a service users guide, statement of purpose, and ensured that each resident has a contract with the Home. We have ensured that we have got feedback from the resident about aspect of the care provided and areas where we could improve. 2 care files were examined, the pre admission assessment for the most recent admission to the home had taken place to ensure that the home could meet the prospective persons social, health and care needs. The assessment appeared detailed and comprehensive. All the people using the service were happy with the rooms provided for them and a stair lift has been provided to assist people to their rooms, the manager confirmed that equipment would be provided where there was an assessed need. Contracts were examined at this inspection and were seen to contain details of terms and conditions or residency and included the fees charged for each room. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person using the service has a care plan, most of the assessed areas of need were reflected in this plan of care and the detail recorded ensures that staff can provide a good standard of care. Staff were observed to treat service users with dignity and respect at all times and residents fell well cared for. Medication systems were of an appropriate standard EVIDENCE: The homes AQAA states that Every service user has a detailed care plan developed by the manager in consultation with the service user. The care plan is regularly reviewed every month to ensure the service user’s Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 13 needs are still being met. We are pro-active in promoting service users health with blood pressure monitoring, weight checks, chiropody services being undertaken. We encourage service users to have regular checks with their GP and associated health professionals. When taking over as manager of the home, Mrs Ngorima found that there was no documentation including care plans, for people using the service, therefore care plans have had to be re started. The Commission is aware that initial care plans were undertaken and that an improved system had recently been started and therefore care plans are in a early stage of re development. All 3 care plans were examined, each person has received a needs assessment and a care plan developed from that assessment. Most areas of identified need had an associated care plan. However, areas which had been identified in the assessment or daily records did not have a care plan in place, this was discussed with the manager to ensure further development takes place to include all areas within the care plan. From the details provided staff were able to provide the care needs identified. Some risk assessments were in place to ensure that independence can be maintained in the safest possible way. Some risk assessments were missing for areas of identified risk and further development is needed to ensure that all risks are managed safely. There are currently only 3 people using the service the daily record is only completed if there are any changes in condition or related information to record. It is recommended that a daily record be maintained for each person. Residents and relatives were consulted in the care planning process and the routine monthly reviews. Support was evident from visiting health professional where an need had been identified and records were maintained of GP and District Nurse visits. The inspector spent time observing the care being given and noted that the member of staff treated people using the service with dignity and respect at all times. People using the service appeared relaxed in the company of the staff and the atmosphere was happy and calm. One person told us that ‘Jane is nice and looks after us well’. The medication systems were assessed to be appropriately managed. The home has written protocols in place on the Medication Administration Records for the administration of most medications. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 14 There were no gaps evident in the Medication Administration Records and the registered manager explained that she is the only member of staff who administers medications. There was evidence of variable doses being recorded and hand transcribed entries being signed by 2 staff, however it was noted that on 2 occasions these hand transcribed entries were not dated when received or the quantity received recorded. This is required to enable a clear audit trail of the date of medication commencement. 2 prescribed creams were noted not to have been dated when opened. This is recommended to ensure that creams are not used after the date of expiry. People using the service have the option to self medicate should they want to, at present nobody has taken this option. Lockable storage is available as required. A homely remedy policy is in place with signed consent on agreed protocols by the relevant GP’s. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are opportunities for social stimulation and people are supported to join in with organised activities or pursue their own interests. The choice of activity is led by the preferences of people using the service. The recording of activities is recommended for further development The meals in the home are of a good quality and a range of choice is available. EVIDENCE: The homes AQAA states We have introduced board games and jigsaw puzzles to help with mental agility. Residents have a choice in what they do rather than just have the television on all day. We have bought drawing materials for a service user to pursue his interest in sketching. The home operates a daily exercise (except weekends) programmes and all service users are encouraged to participate. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 16 People using the service told the inspector that they enjoyed the activities provided and that they were able to receive visitors and access the community whenever they wanted to. They confirmed that they could get up and go to bed at a time of their choosing and that they felt there was enough activities at the home. They told the inspector that they had access to the local day center and stroke unit. A staff member was observed playing dominos with 2 people using the service and one person was reading the daily paper. Activity choice appears to be person centred and people using the service confirmed that they are asked which activities they would like to do. Each care plan contains a social history and choices of activities, however the recording of activities is recommended to be developed to include the level of participation and enjoyment to further improve the person centred approach. There is a choice of lounges for people wishing to receive visitors in private and visitors to the home were seen on the day of inspection. People using the service stated that they had access to a visiting hairdresser and chiropodist and it is recommended that the manager review the provision of visiting clergy to ensure that all spiritual needs can be met. The inspector discussed the meals with people using the service who all confirmed that the standard and choice of food is very good. One comment was, ‘The food is always very good and there is always a choice ‘, the other people using the service agreed with this comment. The registered manager has utilised a previously private room as a dining room to increase the feeling of homeliness. 2 people using the service were seen to enjoy the mid day meal which looked pleasant and appetising and they confirmed that they had enjoyed it. The lunch comprised of fish and chips followed by desert, The evening meal is a lighter meal of sandwiches, quiche, fruit and yogurt, people using the service confirmed that there is always a variety of choice available at both meals. The inspector visited the kitchen and found well stocked cupboards and a good standard of hygiene. In the kitchen fridge some items in plastic storage containers needed dates and labels to identify content. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 17 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff and people using the service are confident that the manager would appropriately deal with any complaints or concerns. Policies, procedures available to staff to ensure they have the knowledge to prevent service users from the risk of abuse require further review to ensure that they are in agreement with the Safeguarding Vulnerable Adults protocol for Somerset. EVIDENCE: The homes AQAA states Written policies in place 2. Complaints procedure readily available 3. We carry our regular care reviews with the multi-disciplinary team and involve service users and relatives. 4. ‘Whistle-blowing’ policy in place 5. Service users are assisted with mobility but not restrained on chair lifts or wheel chairs. 2 people using the service told the inspector that they knew how to raise any concerns and were confident that the manger would respond appropriately. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 18 The home has no ongoing complaints and no concerns about the home and non-have been raised with CSCI. The complaints policy was available within the home and contained the contact details for CSCI. The procedure is cross referenced to the National Minimum Standards for Care Homes. The staff member was aware of the homes whistle blowing policy. The registered manager did not have access to the homes previous policies and procedures and therefore is currently writing the homes policies. These so far included policies regarding complaints, whistle blowing, restraint, and the homes policies for the staff involvement in wills and bequests. The policy in place for abuse awareness does not follow the Safeguarding Vulnerable Adults Policy for Somerset and may cause confusion in its direction to staff. The manager is required to review this policy to reflect the guidance laid out in the Safeguarding Vulnerable Adults Policy for Somerset (May 2007) to ensure that people using the service are protected from the risk of abuse. Discussions with the manager confirmed that she is aware of the risks of abuse and the actions required should a risk be identified. All staff working at the home have received a Criminal Record Bureau (CRB) Check and have been checked against the Protection of Vulnerable Adults (POVA) list. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a large older building, which appears to be well maintained, the home provides sufficient and suitable facilities but requires further attention to some environmental health and safety areas. The standard of hygiene is good. EVIDENCE: The homes AQAA states that within the last six months the home has improved the home by; 1. Creation of a separate dining area 2. Installed soap dispensers in each service users’ room to promote infection control in the home. 3. Use of dedicated laundry bags for each service user. 4. Established maintenance contracts for the fire fighting equipment – this was Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 20 unavailable from previous proprietor. 5. Installed new emergency call aid system and established a service contract for this system. 6. Established cleaning routines for all staff to follow. 7. Provided more soft furnishings and decorated the living areas as previous proprietor cleared out painting and soft furnishings. All bedrooms and communal areas were seen at this inspection. The home is pleasantly decorated with décor and furnishings of a good standard, the home was clean and appeared well maintained. The home provides 1 lounge area and a newly commissioned dining room. All bedrooms seen were of a good size and were pleasant and airy. Access to the second floor is by stair lift, there is a portable step used to access the stair lift. This step can be moved to ensure that the adjacent fire door can close when needed. There are suitable and sufficient toilet and bathing facilities and call bells were available throughout the home. It was observed that an upstairs bathroom window was unrestricted. This window was above waist height and not easily accessed. The manager is recommended to risk assess this window to ensure there is no risk of accidents to people using the service. Bedrooms were personalised with people’s photographs and some small personal belongings and pieces of furniture. TV’s were available in each room as requested. Some areas of the home showed signs of wear and tear resulting form a home of this use. There were loose wires in the dining room and some free standing cabinets need to be risk assessed and possibly secured to prevent the risk of injury. The registered manager confirmed that further maintenance and redecoration is planned. It was observed that cleaning solutions were being stored in both an upstairs corridor wardrobe, stair cupboard and the laundry area. Those areas were not secure and may present people using the service with a risk of accidental ingestion. These were moved to a secure storage area during the inspection. The registered manager recommended to ensure that all substances hazardous to health are stored securely in line with the COSHH guidance. The general standard of cleanliness was very good and there were no malodours evident. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate to meet the assessed needs of people using the service and staff training is promoted to support these people. The induction process for staff includes the Skills for Care, Common Induction Standards. The recruitment procedures within the home require further detail to protect the people using the service from risk. EVIDENCE: The Homes AQAA states All staff have completed application forms, and two references from previous employers All staff have a POVA check done All staff currently working have an in house induction program done. Staff are register to commence the CIFP and NVQ level 2 training. The recruitment aspect of this statement was found not to be the case in all areas. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 22 Since becoming provider/manager at the home Mrs Ngorima has experienced severe staffing difficulties. Recruitment of staff remains ongoing and currently the home is staffed by Mrs Ngorima and 2 other staff members, this has resulted in these staff working long hours to support people using the service. Agency have been used to a minimum. Staffing levels are 1 care staff throughout the day with a staff member sleeping at the home and on call throughout the night. Mrs Ngorima has a plan of action to improve staffing shortages which will be reviewed at the next inspection. People using the service felt that staff were available when needed. Staff training is underway, the registered manager is qualified as a registered Psychiatric Nurse and is registered to commence the NVQ Level 4 Registered Managers award. One staff member is currently completing an induction program at the home which is in line with the Common Induction Standards. The remaining member of staff has not completed an induction but is not involved in care of people using the service and has a supervisory role only. Staff have received training in first aid, basic life support, moving and handling and infection control. Staff fire training has taken place and abuse awareness training is planned for the near future. Recruitment files were examined for all staff. The 2 staff employed at the home by Mrs Ngorima did not have appropriate recruitment records available. As stated in Standard 18, all staff have a CRB and POVA check in place, however, there were no application forms, references or employment history available for the staff in post. This is required to ensure an adequate recruitment audit trail. Mrs Ngorima is fully aware of the employment history for each person but it is not recorded as they are well known to the manager. The urgency of their employment was as a result of severe staffing difficulties. There was evidence that prospective staff are undergoing a thorough recruitment process. The registered manager Mrs Ngorima is required to ensure that all staff, including staff currently working at the home complete a full recruitment procedure to ensure that a clear audit trail is in place and there is no risk to people using the service. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 36 37 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is managing the home through a difficult transition period. Quality assurance procedures are in place to assess the care being provided. Records are stored in line with the Data Protection Act. Some health and safety procedures need to be reviewed to ensure the safety of people using the service. EVIDENCE: Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 24 The homes AQAA states that improvements have been made in the last 12 months by; 1. We took over the home with no paperwork in place and have developed the following - Health and Safety Policy with attendant paperwork. - Policies and procedure for the Home as required by law. - Developed infection control policy. - Fridge and freezer record charts. - Service users Guide and Statement of purpose. - A brochure for the use of prospective service users. - Appointment of an accountant. - Fire safety records including fire drills and fire alarm testing. - Recruited a new chiropody service as previous service left when previous proprietor left. - Recruited new mobile hairdressing service as previous service provider also left when previous proprietor left. The registered manager Jane Ngorima has managed the home since December 2007 and is a Registered Mental Nurse. During this time she has experienced difficulties with maintenance, staffing and the lack of documentation provided with the purchase of the home. Mrs Ngorima has been in contact with CSCI during this time and produced a plan of action to support people using the service during this period. Limits on admissions have been maintained by Mrs Ngorima to ensure the stability of the home. Some areas of inspection will be reviewed at the next inspection to ensure that the processes put in place are robust and effective. People using the service confirm that they feel confident in Mrs Ngorima’s management and find her supportive and approachable. Staff meetings are not currently taking place due to restricted staff numbers. Records stored at the home are stored securely and in line with the Data Protection Act. Staff are aware of the need for security of confidential documentation. The home does not hold or manage finances for anybody using the service. Accident records are available for falls noted in the daily record of people using the service. An audit of falls is undertaken within each persons care plan and appropriate action taken in response to any findings. Staff are supervised on a daily basis but due to staffing limitations the process requires formalising. The manager is aware that when staffing levels increase Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 25 supervision of staff will be ongoing and this area will be reviewed at the next key inspection. The home has recently sent out to relatives and people using the service surveys to gather opinions about the quality of the service provided. It was discussed with Mrs Ngorima that it would be good practice to extend this survey to visiting health professionals. Maintenance records relating to health and safety were being managed by an external source and some records were not available until after inspection Records available these included ; Fire records : Fire Extinguishers tested 20/05/08, the fire system and fire inspection took place on the 20/03/08 at the managements request and recommendations made are being implemented. Emergency lighting records are to be forwarded to CSCI offices. No fire drill has yet taken place as the manager is awaiting response and advice from the fire officer however a weekly test of the fire bells takes place. Call bells : A new call bell central box has been fitted , the room call points are checked monthly records to be received. Electricity PAT Tests records and hardwiring certificate to be forwarded. Stair lift serviced 20/03/08 Gas service records to be forwarded Hot Water The hot water temperatures are routinely tested but the manager confirmed these results are not recorded. It is recommended that this be implemented. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 26 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 1 Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 12 (1) Requirement The registered manager must ensure that all areas of identified need have a care plan in place to ensure that staff are aware of all care needs. The registered manager is required to ensure that all medications are signed as received and the quantity received recorded. This is required to ensure a clear audit trail of medications received and administered. The registered manager is required to review the homes policy for abuse awareness to ensure that the procedures reflect the Safeguarding Vulnerable Adults Protocol for Somerset (May 2007). The registered manager is required to ensure that all staff, including staff currently working at the home complete a full recruitment procedure to ensure that a clear audit trail is in place DS0000070933.V364730.R01.S.doc Timescale for action 30/08/08 2. OP9 13 (2) 30/08/08 3. OP18 13(6) 12(1) 30/08/08 4. OP29 19 Schedule 2 30/08/08 Holway House Version 5.2 Page 28 and there is no risk to people using the service. 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. 2. 4. 3. 3. 4. Refer to Standard OP7 OP9 OP12 OP15 OP19 OP38 OP38 Good Practice Recommendations It is recommended that a daily record is maintained for each person. It is recommended that all prescribed creams are dated when opened. This is recommended to ensure that creams are not used after the date of expiry. The registered manager is recommended to review the recording of activities to ensure development of a person centred approach to activity provision. In the kitchen fridge some items in plastic storage containers needed dates and labels to identify content. The manager is recommended to risk assess the upstairs bathroom window to ensure there is no risk of accidents to people using the service. The registered manager recommended to ensure that all substances hazardous to health are stored securely in line with the COSHH guidance. The registered manager is recommended to record the monthly hot water checks to ensure the safety of people using the service. Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 © 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 Holway House DS0000070933.V364730.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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