Inspection on 14/11/07 for Holywell Nursing Home

This inspection was carried out on 14th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Nursing Home 19/09/06

Holywell Nursing Home 14/02/06

Holywell Nursing Home 19/08/05

Holywell Nursing Home 19/01/05

Holywell Nursing Home 09/09/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holywell Nursing Home Brent Street Brent Knoll Somerset TA9 4BB Lead Inspector Barbara Ludlow Unannounced Inspection 14th November 2007 08:20 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 Nursing Home DS0000003265.V353435.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 Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holywell Nursing Home Address Brent Street Brent Knoll Somerset TA9 4BB 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) 01278 760601 01278 760912 Ms Sarah Elizabeth Joyce Ms Sarah Elizabeth Joyce Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Elderly persons of either sex, not less than 60 years, who require general nursing care. Two places for persons of either sex, aged 40-59 years, who require nursing care by reason of physical disablement, convalescent or respite care. Up to three places for personal care. Date of last inspection 23/01/07 Brief Description of the Service: Holywell Nursing Home is a large detached property situated in the village of Brent Knoll. The home benefits from ample parking, a pleasant garden and views of the surrounding countryside. Accommodation is provided over two floors with a passenger lift giving access to the first floor. Holywell is registered with the Commission for Social Care Inspection to provide general nursing care for up to 25 residents over the age of 60 years (see also conditions). The registered provider/manager is Sarah Joyce who is a dual registered nurse (RGN/RMN). Registered nurses provide 24hr cover at the home. The home has 17 single bedrooms and 4 double bedrooms. Eleven bedrooms have en-suite toilet facilities, some of which are screened by curtains. All bedrooms are fitted with a wash hand basin as a minimum. Some shared rooms have limited space. The fees range from: £504.00 per week and will be varied in line with the level of Free Nursing Care or Continuing Care Contributions from the Primary Health Care Trusts. Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. This inspection visit was carried out over a six hour period. The owner / manager Ms S Joyce was on duty and gave her time to assist with the inspection process. The Annual Quality Assurance Assessment (AQAA) had been completed and was sent to CSCI before the inspection. Questionnaires were sent to service users, staff, relatives and visiting health care professionals. Their comments are included in the report. A tour of the premises was made. The home was very quiet at the start of the inspection as many people were in bed. Residents were seen later in the morning in their rooms and others in the communal rooms. Daily life and activities at the home were observed plus mealtimes, both breakfast and lunchtime. People who live at Holywell, their visitors, staff and visiting professionals were spoken with during the day. Records were requested and sampled. These included the maintenance records, care plans and medication records. Feedback was given to Ms Joyce at the inspection visit and records that were requested by post were received in a timely manner after the inspection. The inspector would like to thank the people living at Holywell, their visitors, visiting professionals and the management and staff for their contribution to the inspection process. What the service does well: Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 6 Holywell offers a friendly, professional nursing care service to the people living there. The service is well managed and the staff team are dedicated to delivering a good standard of service provision. There is a homely atmosphere and attention to the individual needs of the people living at the home is given. The staff are recruited and managed in line with the Care Home regulatory requirements for the safety and well being of the people in residence. There is a good relationship with the local community health care services and attention to the promotion of health and well being was evidenced at this inspection. What has improved since the last inspection? What they could do better: Two of the requirements made at the last key inspection and restated at the random inspection in January this year, have now been partially met. The requirements remain as the quality assurance system and staff supervision were not fully evidenced. The medications fridge temperature was showing a range of readings that were very slightly higher than expected. The thermometer used is not easy to read and needs to be removed from the fridge for the purpose of checking. The office where the fridge is kept was quite warm and may not be the best environment for a sensitive fridge to be kept. A recommendation is made for the assessing the optimum way of managing the fridge at a safe temperature for medications and the taking of daily temperature checks. The treatment / storage room, a non-patient area, was untidy and unhygienic, this must be kept cleaner. Please contact the provider for advice of actions taken in response to this Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 7 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 Nursing Home DS0000003265.V353435.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 Nursing Home DS0000003265.V353435.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): 3, 6 is N/A Quality in this outcome area is good. Pre admission assessment is made prior to admission to ensure that care needs can be met at Holywell. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were reviewed. The people whose care plans were sampled were seen and spoken with. Pre admission assessment had been undertaken and recorded; this information was in the care plans. One pre admission assessment was reviewed in detail; toothache had been a recurrent problem identified pre admission. The care plan identified that dental assessment and Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 10 care was organised on admission to Holywell. The dentist from the community hospital was seen and spoken with on the day of the inspection. Eight respondents to the CSCI questionnaire said they had received a contract at the home, one said they had not. Comment was made that there was ‘good communication with the home’ and they were ‘very pleased’. Eight respondents also said they received enough information about the home prior to moving in. One person commented that ‘the matron had visited’ them. One said ‘no’. Visiting professionals made positive comments about Holywell. One person said they would like a quicker response to a request for pre admission assessment. Another comment included that people in residence appear ‘safe and happy’. Holywell Nursing Home DS0000003265.V353435.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): 7,8,9,10 Quality in this outcome area is good. Care plans were in place for all service users. Person centred health and personal care is delivered in line with the care planning in a respectful and dignified manner. Medications are managed safely. A recommendation is made about the management and regular monitoring of the medications fridge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspection commenced at 0820am and during the first part of the morning people were seen coming into the lounge. One person said they had just had a bath and were ‘nice and warm’, their hair looked tidy and they were given a drink and had their own box of tissues beside them. They went on to say they get up at 7am each day and for breakfast they always have porridge, tea and toast. The person knew their key worker by name. Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 12 A tray is set up so everyone can have a hot drink as soon as they come into the communal lounge to sit down; this practice was observed and worked well. Tea and biscuits were also served mid morning when all those who were able or chose to, had come down to the lounge. In the small lounge downstairs one person was sat was sat cuddling a teddy bear, a cold drink was beside them, they were warm and looked comfortable and appeared to be content. The interactions between staff and people living at the home were observed and heard during the routines of the morning, all were polite and respectful. One person commented that ‘the carers live up to their name’. The doctor visited during the inspection and when asked said she was happy with the care delivered at Holywell. Staff were diligent in raising concerns about individuals, their treatments and medication with the Doctor to achieve a best outcome for the persons concerned. Four care plans were sampled. These demonstrated attention to a person centred approach and very detailed assessment and monitoring of health and well being. Regular reviews of care are made and are recorded. Families are contacted to advise them of a review and they are invited to attend where appropriate. Consent was documented for interventions such as bed rails. These are regularly monitored for safety and the records were forwarded to CSCI after the inspection to confirm this good practice. One set of rails were considered to be low in position due the mattresses in place, this was reviewed at the inspection. Dental assessments are made and treatments are organised where needed. The local dentist from Burnham Community Hospital was making a house call at this inspection; others from their care plans had attended the dental clinic by appointment. Weight is recorded and nutritional assessment. Nutrition is supplemented where needed and one person was seen to have ‘build –up’. The Waterlow score is used to assess the risk of pressure damage. Equipment such as overlays and alternating air pressure mattresses and cushions are available to use to prevent pressure sores developing where a risk is identified. Records seen confirmed that allergies and observations are recorded. Also community care reviews are carried out and are prompted when a change in health and condition affects the dependency and well being of a person. The Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 13 mental health care team are also called upon when a specialist mental health care review is needed. 10 people living at the home returned questionnaires. 8 said they always receive the care and support they need, 2 said always. All 10 responded ‘yes’ when asked if staff listen and act on what they say. 8 said staff were ‘always’ there when they need them and two said ‘usually’. 6 said they ‘always’ receive the medical support they need 4 said ‘usually’. Medication administration records were sampled, the fridge temperature record for 10/11/07 and 14/11/07 was recorded as 10 degrees Celsius and the range was 7 – 10 degrees Celsius. The fridge thermometer was not easy to use the accuracy of the results could be questioned. A recommendation is made to review the management of the fridge. The office with the fridge and medication store was untidy and the basin had a nasal cannula in it, this was removed and discarded by the deputy. One full sharps bin and an overfilled sharps bin were seen in this room. The first aid box was examined, sterile water in first aid box had date expired on 07/2004, and the deputy discarded this. Controlled Drugs were examined and were all correct as per the controlled drug record book. Holywell Nursing Home DS0000003265.V353435.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): 12,13,14,15 Quality in this outcome area is good The home makes visitors welcome. There is a range of activities available to provide interest to people in residence. The menu is varied and nutritious food that is well presented is served. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the morning relaxing music played softly in the lounge as people came to the lounge and were given a morning drink of tea, coffee or squash. Activities were seen to be in progress throughout the inspection visit. Skittles and hand massage, lots of chatting with staff and meaningful interactions were heard. A work experience college student worked alongside the activities coordinator. A newsletter is produced each month by the activities coordinator. This announces news and what is planned for the month. Events such as trips to The Bath and West Show, Sand Bay, Clarks Village, a Fish and Chip meal out, Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 15 Shoe Boxes for Africa. And the Nov 28th Meeting re Christmas lunch were some of the things mentioned. Visiting relatives were seen; one person expressed their gratitude to the care by staff at the home for their relatives health gain since admission to the home. Lunch was served at tables over chairs; some at the dining table and some people were served in their rooms. Help given in a discreet and kindly manner and ‘one to one’. The food was nicely presented and looked appetising. The kitchen was clean and well organised. The kitchen assistant starts work each day at 8am, the cook at 9am. The night staff prepare and give out up to ten breakfasts each morning, the day staff attend to all rest. Kitchen staff confirmed having received some training and instruction in health and safety and Care of Substances Hazardous to Health, (COSHH) There were three diabetics’ diets and nine soft diets to be catered for. Also some people had extra nutritious food to help their weight. The cook said that there had been an Environmental Health Inspection on 11/09/07 when all was fine the exception being the cleaning required for the freezer seals. Refreshments were served throughout the morning and cold drinks were available at all times. Assistance and supervision was given discreetly with regular drinks being offered and taken. One person said they were very pleased with the new fish tank in he corner of the lounge, which was purchased with money from the homes fundraising events. People responding in writing said in response to ‘Are there activities that you can take part in?’ responded 4 said always, 1 said yes, 1 said usually, 3 said sometimes and 1 said never due to their poor sight. Comment received in writing about the food was 5 said they always like the meals in the home, 1 added that they are ‘excellent’, 4 said usually. Holywell Nursing Home DS0000003265.V353435.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): 16,18 Quality in this outcome area is good. Recruitment and employment practice promotes the protection and safety of people living at Holywell. There is a complaints procedure that is clearly displayed for the people and their relatives or visitors to access. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were sampled; all had PoVA first checks and enhanced Criminal Record Bureau checks. The AQAA states that references are authenticated. There have been no complaints made to the home in the last 12 months. CSCI have not received any complaints about the service. The complaints procedure is available in the front hall for all visitors to the home to see and refer to. There is a whistle blowing policy for staff to offer them some protection if they raise concerns about the home. Staff disciplinary policy and procedure is guided by the registered Care Home Providers (RCPA) The processes for monitoring, storing and safeguarding any pocket monies held by the home are in place and access is appropriately restricted and records are kept. Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 17 People responding in writing said ‘Yes’ all knew how to make a complaint. 5 said they knew who to speak to if unhappy, 4 said usually. Holywell Nursing Home DS0000003265.V353435.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): 19,26 Quality in this outcome area is adequate. Although not purpose built the home has been suitably adapted to provide nursing care. Holywell offers elderly frail people a comfortable and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has received some investment in decoration and new carpets in the past twelve months. The home has been suitably adapted to meet the needs of the resident client group receiving general nursing care. The home has assisted bathing facilities and a walk in shower facility. Adjustable beds are being purchased, three new beds have been bought and three more are on Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 19 order. There are patient hoists to assist with patient handling and pressurerelieving equipment is available to meet nursing care needs of the people in residence. There is a separate sluice facility. The home is well maintained and checks are carried out on the fire alarm and fire equipment is serviced and maintained. There is a nurse call bell system throughout the home. The home employs dedicated cleaning staff. Service users commented in writing 7 said the home is ‘always’ fresh and clean, 2 said usually. No unpleasant odours were detected and the bedrooms were all clean and presented in a homely way with pictures, greetings cards, photographs and items such as ornaments and small pieces of furniture. The communal areas were generally clean, comfortable and were homely in appearance. One rusting commode was seen that needed attention or to be replaced. Infection control is generally well managed around the home and there is access to staff hand washing facilities. Staff have access to personal protective clothing such as gloves and aprons to reduce the risk of cross infection with some personal and health care tasks. The office / treatment room was untidy and one full sharps bin and one overfilled sharps bin were seen. A nasal cannula had been left in the basin; this was discarded at the time of the inspection. Care must be taken to maintain a higher standard of hygiene in this non-patient area. Holywell Nursing Home DS0000003265.V353435.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): 27,28,29,30 Quality in this outcome area is good. There is a registered nurse on duty at all times supported by a dedicated skill mixed staff team. Staff are safely recruited and trained to deliver a good level of care to the people living at Holywell. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff on duty during the inspection were seen and spoken with. The home employs a skilled mixed team. There are separate catering and domestic / laundry staff. Activities are undertaken by staff experienced in care but in dedicated activities time. One activities person was on duty in the lounge throughout the inspection day. The AQAA states that senior staff preparing the rota ensures a skill mix is achieved. The home has a core of staff that have worked with Ms Joyce at Holywell for a number of years. Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 21 Staff meetings are held and staff supervision has been introduced. On the day of the inspection, which started at 8.20am, there were 24 people in residence. The deputy manager was on duty and working 7.45am to 8pm. Ms Joyce came to the home a little later. Handover from the night staff had taken place at 7.45am. Four care staff were on duty in the morning, two were senior care staff. Senior care staff are trained to NVQ Level 2 or 3. The afternoon shift had three care staff to 8pm and one until 9.30pm working a twilight shift alongside the night staff team of one trained nurse and two carers who start work a 8pm. There was a sufficient staff number on duty. The registered manager encourages all staff in their personal development and provides opportunities for them to attend relevant NVQ and clinical training courses. The inspector heard that the home is busy at lunchtime. Lunchtime was observed and timely attention was given to those who needed assistance and no one was hurried. Service user feedback in writing indicated that there are staff available when needed, 8 said always, 2 said usually. 10 staff gave written feedback to CSCI; this included much positive comment such as good recruitment practice. Another said that if ever they are short of staff this impacts upon the time they could spend with the service users. Staff said they would like more in house training and more opportunity to debrief after the death of a resident of the home; this was fed back to Ms Joyce. Comments heard from service users included, ‘I would like carers to stay and listen to the answer to the questions they have asked me’ another said ‘staff show patience and kindness’, another said the staff are ‘second to none’. Of the registered nurses they were described as ‘pleasant and professional’, ‘I have confidence in them’ and staff provide the ‘very best care available’. One relative commented on the health gain their relative had experienced as a result of the care taken to look after them at Holywell. Staff recruitment was inspected, three staff files were seen. All had necessary checks in place to promote and protect the safety of vulnerable people in care homes. Holywell Nursing Home DS0000003265.V353435.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): 31,33,35,38 Quality in this outcome area is good. The home is well managed and well maintained. Quality Assurance monitoring is being developed and more meetings are now held. All feedback is used towards improving the service for people who live at the Holywell. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Provider/Manager, Ms Sarah Joyce is a Registered Nurse (RGN & RMN). Ms Joyce also holds a recognised qualification in specialist care of the elderly (ENB 298). Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 23 The Registered Provider/Manager has many years nursing experience and is committed to the care of the residents at the home. Ms Joyce has recruited a deputy to assist with the management of the home. This person is also is an experienced nurse. There is an experienced administrator/ financial controller who helps with the management of service users accounts, pocket monies and general day to day accounting and administration for the care home. Ms Joyce manages the home and retains a hands on role at the home and knows the people in residence and their relatives well. Ms Joyce keeps professionally up to date and maintains her clinical skills. One person said the manager attends to her specialist leg ulcer treatment each week. Quality Assurance has received attention. Ms Joyce is holding more regular staff, relatives and trained staff meetings. Fundraising at the home has made possible a purchase for the home; the people in residence chose to have a tropical fish tank for the lounge. This has been purchased and is now being slowly stocked with fish. The fish tank is closely monitored and much enjoyed by the people in residence. Maintenance records were sampled, The fire alarm servicing was carried out under contract. The passenger lift was serviced on 7.06.07; the contract for the mobile hoists was renewed on 24.08.07. The fire extinguishers were serviced on 8/03/07. Ms Joyce posted records for routine equipment testing that were not seen at the inspection to CSCI promptly after the inspection. These included the hot water temperature failsafe valve monthly checks. Bed rail checks carried out each month. Fire alarm testing which confirmed routine weekly testing and rotation of check points. Weekly fire door testing and monthly emergency lighting tests. The monthly lift bell test. The monthly nurse call testing. The two monthly wheelchair checks. Holywell Nursing Home DS0000003265.V353435.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 2 X 3 Holywell Nursing Home DS0000003265.V353435.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 OP33 Regulation 24 Requirement The registered manager must introduce a formal system of quality assurance monitoring in all service delivery areas. This was partially met at this inspection. 2. OP36 18 (2)(a) The registered manager must introduce formal supervision for all staff groups. This was partially met at this inspection. 3. OP26 13(4) Care must be taken to keep the non-patient office / storage areas clean and hygienic. 14/01/08 14/01/08 Timescale for action 14/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 26 1 OP9 The measurement of temperature should be taken accurately each day. The medications fridge and the temperature monitoring should be reviewed to ensure the temperature remains within the safe range for the storage of medication. Holywell Nursing Home DS0000003265.V353435.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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