Inspection on 16/05/07 for Holywell Bay Care Home

This inspection was carried out on 16th May 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

Holywell Bay Care Home 21/04/09

Holywell Bay Care Home 11/11/08

Holywell Bay Care Home 24/04/08

Holywell Bay Care Home 08/10/07

Holywell Bay Care Home 04/12/06

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

CARE HOMES FOR OLDER PEOPLE Holywell Bay Care Home Rhubarb Hill Holywell Bay Newquay Cornwall TR8 5PT Lead Inspector Elaine Bruce and Alan Pitts Key Unannounced Inspection 16th May 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 Holywell Bay Care Home DS0000068129.V335377.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. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holywell Bay Care Home Address Rhubarb Hill Holywell Bay Newquay Cornwall TR8 5PT 01637 830801 01637 831119 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) Newport Care Limited Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (45) Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents to include up to 4 adults under the age of 65 years An application must be made to the CSCI by the home manager to become the registered manager within 6 months following the registration date. 4th December 2006 Date of last inspection Brief Description of the Service: Holywell Bay is situated close to the beach and a few miles from Newquay. The home is registered to provide care with nursing and accommodation for up to 45 older people who have care needs with a dementia or mental health. The home is owned by Newport Care Limited. Accommodation is provided on the ground and first floor which are linked by a shaft lift and stairs. Large communal areas are provided in the centre of the home on the ground floor. There is a small enclosed garden area and car parking externally. Some bedrooms, notably those on the first floor overlook the sand dunes and golf course. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection at Holywell Bay took place over two days with two inspectors (20 hours). Key standards assessed included an inspection of the safety and cleanliness of the home, medication, meals, staffing to include training and recruitment, policies and procedures and the management arrangements for the home. The home is without a registered manager at this time following a recent withdrawal of an application by the existing acting manager. It is anticipated that a new manager will be soon recruited by the Company. The acting manager was on duty during the course of the inspection and a representative from the Company were in communication with the acting manager during the course of the inspection. The home has a number of residents who have very complicated care needs to include frailty and challenging behaviour. Conversations with these residents were therefore limited and observations of care delivery took place during the course of the inspection using a recognised observation tool. Conclusions from these observations were that staff were noted to treat the residents in a kind and caring manner and that observations and interactions between the staff and the residents were positive. Adult protection procedures have been followed following the last key inspection on the 4th and 5th December 2006 and two complaints received in January 2007. Each resident has been re-assessed by a multi-disciplinary team. There have been no new placements to the home at this time. Prior to the inspection a pre inspection form was completed by the home. The range of fees at the home per week is from £478.67 to £700.00 What the service does well: The dependency levels of residents at Holywell Bay is high. A number of the residents are very frail and a number of the residents have challenging behaviour. Observations of staff and resident action was generally noted to be positive. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 6 The catering cover for the home is good. A cook is employed every day of the week from 0730 to 1800. This allows the staff time to be able to concentrate on their care delivery duties rather than meals. What has improved since the last inspection? What they could do better: The two day inspection at Holywell Bay has identified a number of areas where they “could do better”. There are a number of statutory requirements included in this inspection report, which must be addressed within the timescales to avoid enforcement procedures being implemented. Although staff were noted to be kind and caring the training for staff must be improved. For example at this time staff have received no training specifically for the client group that they are caring for. In addition the nursing staff are not receiving any updated professional training. It is also essential that staff supervision commences at the home. Temporary measures are in place for essential fire improvement maintenance work. These temporary measures have been approved by the County Fire Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 7 Brigade. It is though essential that the extended date for compliance of the permanent work is met. It is recommended that consideration be given to employing a part time staff member for social activities and one to one time with the residents. Although the staff initiate these activities when they can they are noted to be very busy delivering basic care to the residents. 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. Holywell Bay Care Home DS0000068129.V335377.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 Holywell Bay Care Home DS0000068129.V335377.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): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A resident guide is in place to ensure that residents have written information on the services that the home provides. The statement of purpose document requires additional information to meet the requirements of legislation. An assessment of care needs takes place by the acting manager on any new admission to the home to ensure that all care needs can be met. EVIDENCE: The resident guide has been updated with important information since the last key inspection in December 2006. This important documentation clearly mentions that the home is able to cater for the diverse range of needs of the Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 10 residents. The resident guide has been given to the representative of each resident. The statement of purpose document has also been updated but essential information to include for example all the requirements of schedule are not in place An admission procedure is available to guide staff on best practice. Prior to admission the acting manager assesses all potential residents to ensure that the home will be able to meet their needs. A pre admission document is completed prior to admission and assessment information is also accessed by the funding authority. There have been no admissions to the home since the last key inspection report. A multi-disciplinary team have recently reassessed all the residents at the home to ensure that their care needs are being met. Adult protection procedures have been followed to discuss the outcomes of assessments and inspection requirements. Holywell Bay Care Home DS0000068129.V335377.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): 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. The resident’s health, personal and social care needs are being met as evidenced by care planning and direct observation. Medication arrangements were found to be satisfactory and two good practice recommendations are made in this report to ensure medication administration is at all times safe. The majority of the resident and staff interactions were noted to be very positive. EVIDENCE: All the residents have a comprehensive plan of care in place. The care plans include the activities of daily living, mental health needs, social care needs, mobility and moving and handling assessments and pressure sore risk Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 12 calculations. The care plans are completed by the qualified staff and are supported by good daily day and night records. In addition documentation is in place for daily care delivery. It is noted that new bath hoist equipment and wheel chairs have been purchased to help the staff with these tasks. The daily care records indicate that aspects of care to include fluid and dietary needs, general well-being and mood of the individual are commented on well in the daily records: for example: “enjoyed bath today”. Regular reviews of the care plans are taking place but it is noted that some of the care plans are a number of years old. It would be appropriate for these to be commenced again. It is also noted that there is no involvement of the representative of the residents’ in care planning. This is included in this inspection report as a good practice recommendation. All the residents are registered with a general practitioner. The local general practitioner visits the home on a weekly basis (or at any other time if required). Chiropody and dental services are available in the home as required. Good dietary information is included in care planning and daily records include all meals and drinks, but nutritional screening information is out of date and therefore not reliable. This should be updated as soon as is possible. The home refers directly to the tissue viability nursing staff and continence nurses as required. The residents are regularly weighed. During the course of the inspection the following were noted using a recognised observation tool of screening: Observations of residents in the communal areas occured over a period of approximately 1.5 hours using the CSCI SOFI tool: • • • • • Approx 88 of the observations showed residents in a positive state of well-being, when they appeared generally happy, contented, comfortable, and relaxed. Approx 25 of observations included residents interacting with each other or with staff. Approx 33 of observations showed residents engaging with their environment in activities’ which had purpose to that individual. Approx 98 of interactions with staff were seen to be good: providing residents with the feeling of safety, are sensitive and assist the individual to be in control of their actions and lives. Of the remaining 2 or less these staff interactions were predominantly neutral and indicative of a high workload pressure on the staff (task driven). One staff member was observed to commence feeding a resident and then took the breakfast away completely in order to answer the telephone, which led to unnecessary confusion for the resident. This has implications for leadership and effective allocation of responsibilities. DS0000068129.V335377.R01.S.doc Version 5.2 Page 13 Holywell Bay Care Home One resident (not included in the SOFI) requested a shave from staff, but was told he could have one tomorrow, and then later by another staff member that he could have one in the afternoon. This does not support the residents’ individuality and independence, dignity and choice. The medication administration policy and procedure is satisfactory and medication administration records were also found to be satisfactory on the day of the inspection. All the nurses employed by the home have medication administration duties. As discussed at the time of the inspection although the home has a contract with the local pharmacy the arrangements for the disposal of medicines were not in keeping with policy. In addition oxygen is being used when not prescribed and therefore these cylinders should be returned. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 14 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. Care planning evidences that the social care needs of the service uses are identified. It is recommended that consideration be given to employing a part time staff member to organise and commence activities at the home and generally improve the quality of life for the residents at the home. The home welcomes all family and friend visitors to Holywell Bay and encourages them to stay in touch with their relative. Catering hours at the home are good which allows the cooks time to ensure that nutritional needs are met. EVIDENCE: Care planning documentation identifies the social and spiritual care needs of the residents. The daily records provide some evidence of how these needs are being met. There are references in the daily records to visitors and mood and entries have been individualised for example: “enjoyed his lunch and Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 15 glass of bitter”. There are though limited entries on how the residents are spending their day at the home. A discussion took place with the manager following the observations of staff and resident interaction. The staff at the home are very busy delivering basic care to the residents. On day one of the afternoon of the inspection time was spent with the residents listening to music and interacting. It is recommended that consideration be given to employing a staff member to help with these duties and generally improve the quality of life to the residents. Visitors are welcomed to the home (at any time) and the home actively encourages all family/friends to stay in touch. It required there is accommodation at the home where a family can stay if they need to. On the days of the inspection breakfast took place over a number of hours as did the waking and rising time of the residents. It is apparent that the residents are helped to exercise choice and control over their lives which is a credit to the staff considering the majority of the residents cannot verbally express their choices. The main cook at the home is a long standing employee. She is fully aware of the likes and dislikes of the residents and is able to provide a menu choice to meet the resident needs. She is supported in her duties by another long standing employee. Records are in place of meals provided as required by legislation and the home keeps records as required by the District Council Environmental Health Officer Safe food Handling. All specific diets are catered for to include liquidised and diabetic meals. The menu changes over a two week period. On day two of the inspection the main meal of the day was liver with vegetables and potatoes or sausage and chips. The tea time meal was to be corned beef hash and tomatoes. The catering cover for the home is good with a cook being employed every day from 0730 to 1800. This is positive for the staff and the residents. It is noted that the new cooker is in place and other essential equipment has been replaced in the kitchen. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 16 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 poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure that requires further updating to ensure that information is presented more clearly. Adult protection policies and procedures are in place to guide staff on good practice. The lack of training for protecting residents places them at possible risk. This was also the outcome judgement for the inspection report of the 4th and 5th December 2006. EVIDENCE: The home has a complaints policy and procedure in place which although updated requires further clarification. There is confusion when reading the documentation. There is the suggestion that the ombudsman is contacted before the CSCI which is incorrect. It is important that the processes are clearly clarified so family and friends can understand whom they need to contact with any concerns. The home has a policy and procedure in place with regard to the protection of vulnerable adults and a copy of Cornwall County Council adult protection policy and procedure is available. There was no evidence in the random inspection of Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 17 staff files that staff have received training in this important area. This was included in the inspection report of the 4th and 5th December 2006 as a good practice recommendation. It is now included as a statutory requirement. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment at Holywell Bay has been neglected externally and internally during the change of ownership of the home. Improvements are now taking place to the benefit of the residents and staff. The standard of cleanliness on the days of the inspection was noted to be satisfactory. EVIDENCE: Externally, Holywell Bay is in need of essential decoration. The Company will be undertaking this task when other essential high priority internal work has taken place. Since the inspection of the 4th and 5th December 2006 furniture in communal areas has been replaced to include settees and chairs and tables. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 19 Curtains are being replaced and decoration to include painting has commenced and is ongoing in communal areas and bedrooms. Essential fire safety maintenance work has taken place and temporary measures (which are satisfactory to the County Fire Brigade) have also been put in place. There is a statutory requirement included in this inspection report for this high priority work to be completed in three months. An inspection by the County Fire Brigade will take place after that time. Work on improving the toileting facilities at the home has commenced. This will considerably improve the task of toileting for the care staff. The new toilets will allow the easy transfer to residents from wheel chair/hoists to the toilet. Two cleaning staff are employed at the home covering 40 hours a week. The standard of cleanliness at the home on the days of the inspection was noted to be satisfactory although there are some specific areas that could be improved. It is recommended that a schedule of cleaning be drawn up where attention to cleaning of the door handles (for example) and bathroom vents could then be included. The laundry is well provided with industrial machines and a part time staff member for these duties. The part time hours will need to be increased when occupancy levels at the home rise. It is noted that sheets and towels, pillows and duvets are of a poor quality. It is recommended that further documentation is kept of all maintenance work undertaken at the home as at this time this there is not enough information in place. On the second day of the inspection an immediate requirement sheet was left to request a written building works/maintenance plan with supporting evidence and timescales to be sent to the CSCI by the 25/05/07. It is requested that essential work such as fire requirements are included in this documentation. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory to meet the basic care needs of the residents at this time but management must direct and ensure staffing is available to the residents at all times. Residents are placed in a position of possible risk due to a lack of mandatory and good practice training. Recruitment procedures were found to be satisfactory. EVIDENCE: On day one of the inspection the staffing rota had been amended to cover for staff sickness. Staffing levels are satisfactory to meet the basic needs of the residents at the home at this time. When the manager is on duty she must be identified on the staff rota. It is anticipated that improvements will be noted to staffing levels when another manager (nurse) is employed at the home. It was also noted during the course of the inspection that there were occasions when there was no staff cover on the floor in the communal areas. This was due to Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 21 the break allocation which must always be arranged in the best interests of the residents not the staff. In addition to the care staff there is a full time administrator to support the acting manager in her duties. This full time administration support is essential at this time due to the large amount of tasks that have to be undertaken Improvements are noted to the induction training that staff are receiving. This is now in line with good practice Skills for Care training. Moving and handling training is evidenced as taking place but the evidence of the competency of that staff training member was unavailable on the day of the inspection. Fire drill training is evidenced as taking place but at this time there is no one deemed to be “competent” to undertake this training. On the day of the inspection the nurse in charge of the shift had received no fire drill training. It is noted that nursing staff employed at the home are not receiving any training to update their nursing qualification. It is also noted that care staff do not have any training on the client group that they are caring for, for example dementia training. Staff files evidence that staff are being recruited with criminal records bureau checks and written references Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. This inspection has identified a large number of requirements that are not met. Basic care needs of the residents are being met, but staff require direction and leadership to move the home forward. EVIDENCE: The home is without a registered manager at this time. The acting manager had applied for the post and later withdrew her application. She is presently still acting up as manager. It is anticipated that a new manager will be in post very soon. Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 23 A representative from the Company who own the home is regularly in touch with the acting manager and is fulfilling the requirements of legislation by visiting the home monthly and providing a report on the visit to the CSCI. The acting manager is a qualified nurse (RMN). She is supported by the other nurses at the home in her duties. Two team co-ordinators report to the nurses in charge of the shift. The acting manager has undertaken a monitoring of the home by using questionnaires’ to obtain feedback on the care. It is appropriate for the results of these findings to be analysed. For example it was noted that some questionnaire comments suggested that they were unaware of the complaints procedure for the home. Records are in place of the finances of the residents. The acting manager has worked hard to improve the record keeping and auditing of these finances. Each resident has a balance sheet in place which evidences in goings and out goings of expenses. When money is accumulating it is being held in an account with the other residents. The disadvantage of this is that individual interest is not clearly identified and therefore this will have to be looked at. An audit of all the money being held on the premises was found to be correct. There is no staff supervision taking place at the home at this time. This is included in the inspection report as a statutory requirement. An administrator is employed full time at the home to support the acting manager in her duties. Time was spent with this staff member who has a large amount of work to do at this time. It is positive that he is employed full time to undertake the tasks. It is noted that some new policies and procedures for health and safety are in place. COSHH information must be provided at the point of use. Accident procedures and documentation is in place. Maintenance records were inspected and generally found to be satisfactory. Where follow up maintenance work is required the administrator is fully aware of these requirements. Holywell Bay Care Home DS0000068129.V335377.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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 1 x x x x x x 2 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 1 2 1 Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 Regulation 13(6) Timescale for action The registered person shall make 31/08/07 arrangements, by training staff or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall after 31/08/07 consultation with the fire authority take adequate precautions against the risk of fire. The registered person shall 31/08/07 ensure that the premises to be used as the care home are of sound construction and kept in good state of repair externally and internally. (original compliance date 30/05/07) The registered person shall ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. (original compliance date of 31/12/06, second compliance date 31/03/07) DS0000068129.V335377.R01.S.doc Requirement 2. OP19 23(4)(a) 3. OP19 23(2)(b) 4. OP30 18(1)(c) 31/08/07 Holywell Bay Care Home Version 5.2 Page 26 5. OP36 18(2) 6. OP38 13(5) The registered person shall 31/08/07 ensure that persons working at the care home are appropriately supervised. The registered person shall make 31/08/07 suitable arrangements to provide a safe system for moving and handling residents. (original compliance date of 31/12/06, second compliance date 31/03/07) The registered person shall take 31/08/07 adequate precautions against the risk of fire. (original compliance date of 31/12/06, second compliance date 31/03/07) 7. OP38 23(4) 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. 3. 4. 5. Refer to Standard OP1 OP7 OP8 OP9 OP12 Good Practice Recommendations To update the statement of purpose with essential information that meets the requirements of legislation. To update old care plans and evidence the involvement of the representative of the resident in care plan reviews. To update the nutritional screening tool being used for all the residents. To return three oxygen cylinders and make arrangements for the safe disposal of medicines. To give consideration to employing a part time staff member for social care needs activities and one to one DS0000068129.V335377.R01.S.doc Version 5.2 Page 27 Holywell Bay Care Home 6. OP16 interaction time. To clarify clearly the procedures in the complaints policy and procedure. To ensure that recruitment procedures include checks on nurse pin numbers. For the results of the quality assurance/monitoring questionnaire to be analysed. For residents to earn interest on their saving accounts. 7. OP29 8. OP33 9. OP35 Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Holywell Bay Care Home DS0000068129.V335377.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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