Inspection on 21/06/07 for Holyrood House

This inspection was carried out on 21st June 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holyrood House 22/01/09

Holyrood House 22/11/07

Holyrood House 06/07/06

Holyrood House 20/12/05

Holyrood House 17/08/05

Holyrood House 10/03/05

Holyrood House 13/01/05

Holyrood House 20/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Holyrood House 46 Green Lane Ostend Burnham On Crouch, Maldon Essex CM0 8PU Lead Inspector Marion Angold Key Unannounced Inspection 21st June 2007 10:45 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 Holyrood House DS0000017852.V343980.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. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holyrood House Address 46 Green Lane Ostend Burnham On Crouch, Maldon Essex CM0 8PU 01621 784759 01621 784856 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) Mr Peter Walters Mrs Melanie Walters Mrs Melanie Walters Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 Brief Description of the Service: Holyrood House is a detached property that was first registered as a private care home for three older people in 1994. The owners are Peter and Melanie Walters, who is also the registered manager. This home is situated on the outskirts of Burnham on Crouch but is not within walking distance of the towns facilities. Holyrood House caters for three older people in a homely environment, which they share with the owners. As a family home, residents are able to receive consistent day-to-day care and involvement with the owners and a small team of care staff. Residents’ private accommodation is in single bedrooms on the ground floor. Access to the rear garden via patio doors would be difficult for wheelchair users. Adequate car parking facilities are available at the side of the property. As at 21 June 2007, the manager advised that the fees for accommodation ranged from £420 to £450 per week. Items considered to be extra to the fees include private chiropody (£35.00 at the time of inspection), hairdressing, toiletries and newspapers. CSCI inspection reports are available from the home and the CSCI website. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, covering the key National Minimum Standards took into consideration all recent records and contacts relating to the service. It included a site visit to the home on 21/06/07, lasting nearly 6 hours. This visit involved speaking with residents, the owners and manager, as well as a tour of premises, observation of care practice and the sampling of records. Neither of the 2 part-time staff were on duty on the day of the site visit and, although surveys were sent to the home for distribution to relatives, health care professionals and care managers, none have been returned to the Commission. Of the 20 Standards inspected, 8 were met, 9 presented minor shortfalls and 3 gave cause for serious concern. Particular situations warranted immediate requirement notices because they put people at risk in some way. Management’s initial responses to the findings of this inspection have been encouraging and it is hoped that the Commission will not need to take further enforcement action. What the service does well: People living at Holyrood House benefit from a small-scale, family style home and the continuity provided by the manager/owners who live on the premises and know them well. In June 2006, a frequent visitor to the home responded to the manager’s survey with the comments that • • • their relative was very happy the care and service were second to none any special requirements had always been provided. People thinking about coming to live at the home would have an assessment of their needs to determine whether Holyrood House could offer the required care and support. People could expect their healthcare needs to be appropriately monitored and addressed and to receive their due medication. People living at Holyrood House could choose things like when to get up and whether to be alone. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • Develop care plans to ensure that people’s social, emotional and recreational needs are being fully addressed and review care plans every month to take account of people’s changing needs. Maintain the premises and gardens so that people are safe and can fully enjoy their surroundings. Carry out the requirements of the Fire Safety and Environmental Health Officers and any other checks needed to promote the safety of people living and working at the home. Have enough staff available to ensure that the needs of people living at the home are met consistently and that the manager/owners have sufficient breaks to protect their own health and the wellbeing of the people in their care. Carry out all the pre-employment checks required by regulation to protect people from anyone who would not be suitable to work in a care home. Keep a record of people visiting the home to safeguard everyone living there. Log all complaints, detailing any investigation and follow up action required, to help in the process of monitoring and improving standards in the home. At least every year carry out a quality review of the service to ensure that the home’s objectives are being met and that all aspects of provision promote the best interests of the people living at the care home. • • • • • • • 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 Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Holyrood House DS0000017852.V343980.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 Holyrood House DS0000017852.V343980.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): 2. NMS 6 did not apply to Holyrood House. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People thinking about coming to live at the home would have an assessment of their needs to determine whether Holyrood House could offer the required care and support. EVIDENCE: The manager indicated that there had been no cause to amend the home’s Statement of Purpose and Service User Guide. A new person had taken up residence in February 2007. Although this person had for many years lived at Holyrood House under a different arrangement, an assessment of need was completed prior to their admission to the home. Both the manager and the person concerned knew what to expect from the new arrangement and this had made for a seamless transition. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefited from the family style of operations and being well known by the manager/owners but lack of a systematic approach to care management meant some compromise of quality in some areas of people’s lives. EVIDENCE: Each person had a care plan, giving detailed instructions for care in the areas it covered. The care plans varied in breadth, with one addressing a range of needs and another only three key areas of difficulty. This meant that important aspects of people’s lives were not planned for. For example, two care plans did not show how the home was meeting emotional, social and recreational needs. The manager stated that the people currently living at the home did not wish to participate in social and recreational activities; this should be documented in their care plans to show that these areas have been explored. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 11 People did not think they had been involved in any ongoing discussion about their care plan and this was supported by lack of evidence of their participation from the records. The manager said that this was by choice as only one person had been interested in discussing or participating in their care plan. The care plans had been evaluated in April or May 2007 but no comment or amendments to the plans had been made and it was evident that regular monthly evaluations had not been established since the last inspection. One person’s care plan had not been updated following their discharge from hospital with a marked deterioration in their health. It was evident from observation and discussion that the home had increased the support they were giving but records did not reflect this or any of the changes that had occurred. On the other hand, appropriate risk assessments for manual handling and use of mobility aids and equipment were in place and had been reviewed and updated. The home was not keeping records of people’s progress on a daily basis. The manager said they only made an entry if there was anything different to report. The set of records inspected focussed on one particular need and were not clearly linked to the care plan. They also did not show how the person had spent their time. The manager reported that they were well served by the local district nursing service, which provided a link to the GP surgery. Contact with health care professionals was documented in people’s care plans. One of the district nurses indicated that they had no issues with the way the home supported people’s health care needs. Medication for people living at the home was secured in a locked cupboard and held in individual boxes, with photographs attached for identity. The manager was responsible for ordering medication and preparing medication administration records, as these were not supplied by the pharmacy. Records inspected were in order and up to date. The manager had attended a course on the care and administration of medicines but there were no records available to confirm that other staff were suitably trained to be involved in the administration of medication. People living at the home affirmed that they were satisfied with the way they were treated and that their privacy was respected. On the whole this was supported in discussion with the manager/owners and by observation of practice. However, there was potential for the home to improve outcomes in this area for people living at the home. People’s preferences in respect to the gender of staff supporting them with personal care were respected, although this could lead to them having to wait for the assistance they needed. It was evident that two residents had high dependency needs, requiring the assistance of two carers in some situations. As there were not always 2 staff to hand, this also could lead to them waiting for assistance and compromising their comfort and dignity. Records and discussion indicated that such a Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 12 situation had occurred during the week of the inspection. Shampoo was available in the bathroom for communal use but the manager said this belonged to the hairdresser and that all other toiletries were individual and kept in people’s rooms. The manager should consider an alternative to the plastic duvet, pillow and mattress covers on one person’s bed to promote their comfort and dignity. Holyrood House DS0000017852.V343980.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): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of people’s lives would be enhanced by greater attention to the detail of how they each spend each and by giving them more opportunity to be involved in some of the decisions that affect them. EVIDENCE: It was evident from observation and discussion that routines of daily living, such as mealtimes, were flexible, in keeping with the family style of operations. People affirmed that they could go to bed and get up when they chose. One person remained by choice in their room rather than go to the lounge. The daily schedule identified a period in the afternoon when staff were to ‘keep residents safe and happy in whatever they want to do – play games, do nails’. During the site visit, the manager/owners spent time talking with people while assisting them with lunch. One person said that one of the staff team would also come and talk with them sometimes. The manager said residents received occasional visits from local clergy and twice a year from a group of Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 14 hand bell ringers. They also enjoyed fortnightly visits from the hairdresser and occasional sessions with a beautician. However, people’s spiritual, recreational and social care needs were not adequately covered in their care plan or daily records and it was evident that individuals could benefit from attention to the detail of how they spent the day. It was observed, for example, that people sat throughout the site visit in the same chair, without changing their location. They did not go to a table for meals. People indicated that this pattern was typical. One person said they sat where staff put them and did not go in the garden. Televisions were on continuously; the manager said this was by agreement with the two people in the lounge. One person’s position in the room was not ideal because of reflected light on the screen. The visiting policy stated that people could visit between 10 am and 8 pm or by request. The home did not have a record of visitors. Although the manger said they knew who came and went, it is essential that a detailed record be maintained to safeguard people living at the home and provide retrospective information, if necessary. A letter from a regular visitor showed that they felt very positive about what they experienced during their visits. Those without close family had been put in touch with an advocate, although one person said they had not seen their advocate for a long time and this may need following up. People appeared to enjoy their cooked lunch and expressed general satisfaction with the meals provided. Although they were not actively involved in deciding menus, the manager/owners knew and respected their preferences and the daily schedule showed that there was a flexible approach at teatime, with people being asked what they fancied. The owners/manager spent considerable time supporting one person with their lunch to ensure they were able to eat as much as they wanted at their own pace. Holyrood House DS0000017852.V343980.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): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are protected from abuse but their complaints are not always handled in a systematic way that ensures the best outcomes. EVIDENCE: It was evident from discussion, and a situation referred to in one person’s daily records, that people felt they could voice dissatisfaction. The manager said that she had not felt the incident referred to in the daily records warranted separate logging as a complaint. However, it was not clear from the entries in the person’s notes how their concern had been dealt with. When a person expresses dissatisfaction with a member of staff or an aspect of their care (in this case, delay in assisting them with their continence needs) this should be appropriately logged, together with an account of any investigation and follow up action that needs to be taken. A robust approach to complaints helps people know that their views will be listened to and acted on. An audit of people’s views and experience is also an essential part of quality monitoring. People working in the home had access to up to date safeguarding adults guidance and procedures. The manager and one of the staff had also attended related training. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment was homely but not entirely clean and safe for the people living there. EVIDENCE: Holyrood is an old property, full of character and interest but various parts, including the entrance hall and corridors, were in need of refurbishment. During the course of the inspection, people did not use the patio room, which gives a view onto the area of garden designated for them. The front and patio entrances were not wheelchair accessible and residents would need to be able to negotiate a step to go outside. Inside, grab rails and ramps were in place where the floor level was split, to assist people to go between the lounge and dining room safely. Frayed carpet Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 17 at the threshold between these two rooms should be replaced before it becomes a trip hazard. It was encouraging to hear that worn carpet, extending from the kitchen to the bathroom and in entrance hall, was about to be replaced. A person seated in the lounge could not see the television clearly, due to reflected light on the screen. There was no table set up for people to eat together. The manager said that it had been removed to create a sitting area because existing residents preferred to eat at individual tables. The dining table and chairs were still available for use if required. Three requirements, issued by the Fire Authority on 12/9/05, had not been complied with, putting people living and working at the home at risk. The manager had also not implemented food safety procedures in accordance with a requirement made by the Borough Council’s Environmental Health Officer. Some polystyrene tiles were missing from the bathroom ceiling. The owners said this was due to a leak from above. They acknowledged that the ceiling needed to be replaced. The bathroom was also much in need of decorating and refurbishment. Floors did not appear altogether clean on the day of the site visit and two bedrooms were notably dusty. Things under one person’s bed were covered in dust, a situation not helped by lack of storage for their belongings. An armchair without a seat cushion and littered with crumbs was waiting in the dining/patio room to be disposed of. Kitchen surfaces were cleared and cleaned during the site visit and there were no odours in the en suites, although they needed refurbishment. The laundry walls were painted brick and, as such not readily cleanable but, otherwise, laundry facilities were fit for purpose. Communal towels were in use in the bathroom and kitchen, a bar of soap in the bathroom. These should be replaced with paper towels and liquid soap dispensers to reduce the risk of infection. The paper towel dispenser in the bathroom was empty. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home were not fully protected by the home’s staffing arrangements, recruitment, and training practices. EVIDENCE: Staff records were not available for inspection. The manager said she had left them in error at the home of a close relative but gave assurances that their confidentiality had not been compromised. The manager said that the two staff, who had started working at the home since the last inspection, were self-employed and had arranged their own Criminal Record Bureau checks. The self-employed status of staff does not obviate the need for the Criminal Record Bureau checks to be arranged through the home as this offers maximum protection to people living there. The manager said that, as part of the recruitment process, the new staff had completed applications, attended for interview, supplied satisfactory references and completed a satisfactory trial period. Staff were not on duty and there were no records to verify this. The manager said that two part-time staff were employed for 15 and 28 hours a week respectively, leaving the manager/owners to cover the remaining hours between them. The manger/owners also had a tenant to support with meals, Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 19 as well as home and family responsibilities. The manager indicated that they were able to use their staff flexibly if someone was unwell or needed additional support and that they always had two people providing support in the mornings and evenings. However, one of the owners did not provide intimate personal care to all the residents and two residents had high dependency needs, requiring the assistance of two carers in some situations. Under existing arrangements, two people would not always be available to give the necessary support. These factors, together with evidence that the manager was under pressure and not giving sufficient time to management responsibilities, suggest the need for a review of staffing arrangements in the interests of the health and safety of everyone concerned. Although staff files were unavailable, certificates displayed in the kitchen showed that, since July 06, one of the part-time staff had completed training in food hygiene and the protection of vulnerable adults. The manager said this person had covered other health and safety topics in their previous employment and, with herself, would be attending a bereavement course in July 07. Discussions with the manager indicated that the home did not offer a full induction programme, in line with guidance from Skills for Care, the organisation that oversees standards of training in the care sector. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The safety of people living and working at the home was compromised by the lack of management systems and effective quality monitoring. EVIDENCE: Since the last inspection, the manager has achieved the National Vocational Qualification in management and care. One page of the home’s registration certificate was displayed in the kitchen; both pages must be shown and moved to a place where visitors can see them. The owners must also display a valid insurance certificate. The one on display was out of date. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 21 The home did not have a systematic approach to quality assurance. One relative had been asked to give written feedback but surveys had not been distributed to the representatives/advocates of the other people living at the home, or to people visiting in a professional capacity. Management had not sought feedback from the people living in the home. Policies and procedures were not dated and there was no evidence that they had been reviewed as part of the home’s quality assurance process. A number of shortfalls highlighted at previous inspections were still outstanding or only partially addressed. Various breaches of regulation have been identified and remain the responsibility of the registered persons. The manager said they did not hold personal money for any of the people living at the home. One person was independent in this area. The others had a solicitor or family member looking after their affairs. Records showed that the home sought reimbursement from the solicitor, in respect of expenses not covered by their fees, such as the cost of chiropody. Records relating to health and safety were kept, along with other documentation, in concertina file. This was not well labelled and it was necessary to search for the required information. Records inspected showed that safety checks in respects of gas installations and portable electrical appliances were overdue. There were no records to evidence that electrical installations had been checked and serviced or that the hoists in use had been maintained and serviced. The manager said that one person supporting residents had a first aid qualification. If the home does not always have on duty someone who is suitably qualified to administer first aid, they must show how any associated risks to people living at the home have been assessed and planned for. Three requirements, issued by the Fire Authority on 12/9/05, had not been complied with, putting people living and working at the home at risk. These included illumination to the emergency exit in the lounge, self-closure to the kitchen door and annual maintenance of portable fire extinguishers. There were also no records to evidence that the home was carrying out statutory fire safety checks. The manager had also not implemented food safety procedures in accordance with a requirement made by the Borough Council’s Environmental Health Officer. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 2 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 24 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 OP7 OP13 OP37 Regulation 15 17 (2) Sched 4 17 (2) Sched 4 Requirement Care plans must be reviewed on a monthly basis. Timescale 01/09/06 not met. A record must be kept of all visitors to the care home to safeguard the people living there. A record must be kept of all complaints about the operation of the home and the action taken by the registered persons in response to such complaints. Adequate precautions against the risk of fire must be taken. This includes complying with any requirements issued by the Fire Authority and making adequate arrangements for the maintenance of all fire equipment and for reviewing fire precautions, and testing fire equipment, at suitable intervals. All parts of the home must be kept clean and reasonably decorated. Adequate precautions must be taken to prevent and avoid the spread of infection in the home. There must always be sufficient numbers of suitably trained staff on duty to support the needs of people living at the home. CRB disclosure checks must be DS0000017852.V343980.R01.S.doc Timescale for action 31/08/07 01/08/07 3. OP16 01/08/07 4. OP19 OP38 23 (4) 02/07/07 5. OP19OP26 23 (2) 13 (3) 13/08/07 6. OP27 OP10OP30 18 13/08/07 7. OP29 13 02/07/07 Page 25 Holyrood House Version 5.2 8. OP33 24 9. OP29 OP37 17 10. OP38 12, 13(4) 11. OP38 CSA 2000 S 28 obtained for all staff and for new staff before they commence working at the home. Timescale 1/2/06 not met. The manager must consult with residents, relatives and other people with an interest in the home at regular intervals as part of a Quality Assurance system. Timescale 1/9/06 not met. All records must be maintained in a manner that ensures confidentiality and available for inspection. Timescale 1/9/06 not met. All matters relating to Health & Safety must be up to date and records kept available for inspection. Timescale 1/9/06 not met. Both pages of the certificate of registration must be displayed in a place where visitors to the home can view them. 31/08/07 02/07/07 02/07/07 01/08/07 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 OP7 OP12 Good Practice Recommendations People living at the home should have care plans that address their needs fully and these should be evaluated every month to ensure that changing needs are met. Daily records should be maintained for each person living at the home to inform monthly evaluations and show how the home is meeting their needs. Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Holyrood House DS0000017852.V343980.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!