Care Home: Hollymount Nursing & Residential Care Home

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What the care home does well What has improved since the last inspection? The care plans to help to minimise risks to residents` health were more detailed. This meant that staff had better directions on how to promote residents` health and safety. More staff had received training in topics that helped to protect people`s health and safety, for example moving and handling and food hygiene. There had been improvements in the way that the manager and the owners of the home assessed the quality of the service they provided. What the care home could do better: There must be some improvements in the way medicines are recorded and administered in order to safeguard people living at the home. The manager should make sure that background checks for new employees are looked at carefully to make sure that they are fit to work at the home.In order to protect people living, working and visiting the home, the manager must make sure that all staff have fire safety training. CARE HOMES FOR OLDER PEOPLE Hollymount Nursing & Residential Care Home 3 West Park Road Blackburn Lancashire BB2 6DE Lead Inspector Jane Craig Unannounced Inspection 16th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hollymount Nursing & Residential Care Home DS0000022514.V348108.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. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollymount Nursing & Residential Care Home Address 3 West Park Road Blackburn Lancashire BB2 6DE 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) 01254 266450 01254 266451 Longfield Care Homes Limited Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (25) of places Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Within the overall total of 38, a maximum of 24 service users requiring nursing care who fall into the category of either OP or PD Within the overall total of 38, a maximum of 28 service users requiring personal care who fall into the category of OP Within the overall total of 38, a maximum of 1 service user requiring personal care who falls into the category of PD The Registered Provider must, at all times, employ a suitably qualified and experienced manager, who is registered with the National Care Standards Commission. 7th September 2006 Date of last inspection Brief Description of the Service: Hollymount Nursing and Residential Home provides care for up to 38 people who have personal care or nursing care needs. The home is located in a residential area close to Corporation Park and approximately half a mile from Blackburn town centre. The main road with shops and other amenities is within walking distance. Hollymount is an extended detached property. It offers mainly single room accommodation with some en-suite facilities. Ample bathrooms and toilets are located close to bedrooms and communal areas. There are three lounges and a dining area. Decor and furnishings are of a good standard, comfortable and homely. Residents have access to well maintained gardens and a patio area. There are car parking spaces to the front and side of the home. Information about Hollymount is sent out to prospective residents following an enquiry about admission. The latest CSCI inspection report is on display in the manager’s office. At 16th October 2007 the fees ranged between £386.00 and £525.00 per week. There was a supplement for a single person occupying a double room. The supplement was 70 of the rate of the double room and the list of charges indicated a fee of £724.00 for someone in this position. There were additional charges for newspapers, hairdressing and clothing. Residents were also charged a fee for staff escorts to hospital and other appointments. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Hollymount on 16th October 2007. At the time of the visit there were 31 people living at the home. The inspector met with some of them and asked about their views and experiences of living at Hollymount. Some of their comments are included in this report. Three people living at the home were case tracked. This meant that the inspector looked at their care plans and other records and talked to staff about their care needs. As part of the key inspection a number of surveys were sent out to people living at the home, their relatives, staff working at Hollymount and visiting health professionals. Comments received on the surveys have been taken into account when compiling the report. During the visit discussions were held with the responsible individual, the manager, members of the staff team and visitors to the home. The inspector looked round the home and viewed a number of documents and records. This report also includes information from the Annual Quality Assurance Assessment (AQAA), which is a self-assessment that the provider has to fill in and send to the Commission every year. What the service does well: People who were thinking of moving into the home were able to visit at any time. One relative said that this was one of the reasons she chose the home, because it meant that they had nothing to hide. Before anyone moved into the home them manager visited them to assess what care they needed and to make sure that their needs could be properly met at Hollymount. Most people who returned surveys indicated that they were given enough information about the home to help them to make a choice about whether it was the right place. People who returned surveys indicated that they received the care and medical support they needed. Family carers indicated that their relative’s needs were always or usually met at the home. People spoken with at the time of the visit said they were well cared for. One person said, you can’t fault the care; they are very attentive.” Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 6 Staff were observed approaching residents in a polite and respectful manner. One resident said, “They have good manners, say please and thank you.” There was an open visiting policy, which meant that people could see their relatives at any time. Visitors said they were made to feel welcome. There was a programme of social and recreational activities. People were able to choose what they wanted to join. People living in the home were able to make choices about many aspects of their daily lives. One person said, “Some people stay in their rooms, I like to come down and be with people.” The chefs working in the home were qualified to restaurant standard. Residents said they liked the food. One person said, “Good meals and a lovely sweet, you can’t beat it.” The home was clean and free from odours. The décor and furnishings were homely and of a good standard. People living at the home said they were comfortable and they liked their bedrooms. Some of the relatives made comments about the cleanliness of the home. People who returned surveys indicated that staff listened to them and acted upon what they said. A relative wrote, “Staff are all friendly and approachable.” During the course of the visit a number of residents said that staff were very nice and they got on well with them. Over half of the care staff held a nationally recognised qualification in care. What has improved since the last inspection? What they could do better: There must be some improvements in the way medicines are recorded and administered in order to safeguard people living at the home. The manager should make sure that background checks for new employees are looked at carefully to make sure that they are fit to work at the home. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 7 In order to protect people living, working and visiting the home, the manager must make sure that all staff have fire safety training. 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. Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People thinking of moving into the home received sufficient information to help them to make a decision and staff received sufficient information to understand the person’s needs. EVIDENCE: The service user’s guide had been updated and everyone living at the home had a copy. People who completed surveys indicated that they received enough information. A relative said that rather than being given an appointment to look around Hollymount they had been encouraged to just turn up. They said it showed they had nothing to hide and was one of the reasons they chose the home. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 10 Anyone thinking of moving into the home was assessed by one of the senior staff from Hollymount to make sure that their needs could be met at the home. Staff had access to the written assessment and they said they had opportunities to discuss the needs of new people with the manager and their colleagues. Standard 6 was not applicable. Intermediate care is not provided at Hollymount. Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 good. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs were met in accordance with their wishes. Some medication practices were unsafe and could place people at risk. EVIDENCE: Three sets of care records were inspected as part of the case tracking process. All three contained a complete set of care plans that followed the activities of living framework. Plans generally provided staff with sufficient direction to meet people’s needs in the way they preferred. A small number stood out as being highly personalised. Some plans had not been re-written for a number of years but there were records to show they had been reviewed every month. There were some examples of care plans being amended when the person’s needs changed. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 12 None of three plans contained evidence that the resident or their relatives had been given a recent opportunity to be involved in drawing up or reviewing the plan. However, the manager said that care was frequently discussed with family carers but not always documented. A visitor said that she had been invited to look at her relative’s care plans and another relative wrote that they were always kept up to date even with minor issues. Each care file included appropriate risk assessments and, where necessary, guidance for staff on how to manage the risk. These had improved since the last inspection and provided staff with more detailed directions. There was a good example of a risk management plan for the use of bed rails. Residents’ ongoing health care needs were monitored. Any changes were attended to and if necessary people were referred to outside agencies. A health professional who returned a survey indicated that individuals’ health care needs were usually met by the service. People who returned surveys indicated that they received the care and support they needed. The results of surveys from family carers showed that the service was providing the agreed level of care and always or usually met their relative’s needs. People spoken with during the visit confirmed that their health care needs were met. One person said, “I am well looked after here. The district nurses come when I need them.” Another person said that staff were very attentive. Most staff had received training that covered core care values. They discussed how they upheld people’s rights to privacy and gave examples of ensuring doors were closed when they were giving assistance with personal care. Staff were observed speaking to people with respect and approaching sensitive subjects discreetly. People using the service said that staff were polite and respectful. One person said, “They have good manners, say please and thank you.” Some of the requirements made at the last inspection to improve the way medicines were handled had been addressed but there were still a number of shortfalls. Medication received at the beginning of the monthly cycle was checked and recorded but this was not always the case when medicines were received midmonth. This meant there was no audit trail for that medication. There were records of disposal of waste medicines. Not all handwritten or amended Medication Administration Record (MAR) charts were signed or countersigned. This could increase the risk of errors in recording and administration. Medical abbreviations were used which could cause confusion and increase the risk of errors. In one case the handwritten Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 13 instructions on the MAR chart did not accurately reflect the directions on the medicine label. This had resulted in the person receiving an extra dose of the particular preparation than prescribed by the doctor. One MAR chart had been altered to show a reduction in the frequency of administration of the medicine. There was no evidence that this had been authorised by the person prescribing the medication. The instructions had been altered instead of making a new entry. This could increase the risk of confusion and can lead to errors. A random check found that the stocks of medication in the monitored dose system accurately tallied with the records. It was not possible to carry out an audit of this nature on medicines not in blister packs. This was because it was not clear how much stock had been carried forward from the previous month. This meant that the manager would not be able to easily identify if there were errors in administration. For example, 14 tablets had been dispensed for one person. The MAR chart showed 13 tablets signed for and then course complete. There were no tablets left in the packaging. There were very few gaps on MAR charts, generally only in relation to administration of creams. Staff usually used the write code to explain omissions. Controlled drugs were stored safely and stocks were accurate as per the controlled drug register. There was a significant amount of medication belonging to people no longer at the home. Some had not been used since December 2006. There had been no checks carried out during this time to ensure that there had been no mishandling. The manager had had difficulty sourcing a denaturing kit. Hollymount Nursing & Residential Care Home DS0000022514.V348108.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. This judgement has been made using available evidence including a visit to this service. The routines in the home revolved around the residents, who said they were happy with their lifestyle. EVIDENCE: Information about preferred daily routines, interests and religious needs was usually recorded on individual care plans. At the time of the visit, most people said they were happy with their life at the home. One person said, “There’s nothing wrong with this place. It’s great.” Most people who were asked said they could get up and go to bed when they wanted to. One person said, “I like to go to bed early, some like to stay up but I don’t. Nobody presses you to go.” Staff said the home was very relaxed and people had choices in most things. A relative who completed a survey form commented that it was sometimes difficult for the home to support people to live as they chose but they tried. Another commented that their relative was very private and preferred to stay in their room. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 15 There was a programme of social and leisure activities organised by a dedicated entertainment co-ordinator. Records showed that there was a core group of people who took part in the daily games and the co-ordinator said she and the manager were looking at ways to extend the range of activities and try to appeal to more people. There had been some very successful large group activities and events such as a pottery class, a gourmet evening and various entertainers. People who returned surveys said there were ‘usually’ or ‘sometimes’ activities they could take part in. One commented that they did not wish to. During the visit people said they sometimes joined in if it was something they liked. A relative also wrote that their relative was encouraged but not “pressurised” to join in. There was an open visiting policy and relatives said they were made to feel welcome at any time. One relative said that they usually attended the large events, which were always very good. A computer, with Internet access, had been installed for residents’ use with plans to assist people to use it to keep in contact with family and friends. Representatives from the local churches visited the home which helped people to continue to practise their religion. There were limited opportunities for people to go out unless with their relatives. However, there is one person who was supported by staff to go out every week. Information included on the Annual Quality Assurance Assessment (AQAA) indicated that residents had joined a local pensioners club which will involve a trip out to the theatre every month. People who returned surveys indicated they always or usually liked the meals. Everyone spoken to during the visit said they enjoyed the food. One person said, “Good meals and a lovely sweet, you can’t beat it.” Other people commented that the food was always very good and there was plenty of it. Records of meals showed that people were offered a varied and balanced diet. There was an alternative menu at lunchtime and three or four choices for the evening meal. The newly appointed chefs both had restaurant or hotel experience. One described that the menus were mostly plain meals that people requested and enjoyed and they were adding occasional new dishes for people to try. The chef said they used mostly fresh ingredients and most meals were completely home made. The meals on the day of the visit looked appetising. One person who had a pureed diet said they had a special plate so that everything was kept separate instead of being like soup. The dining room was attractively laid out. Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 good. This judgement has been made using available evidence including a visit to this service. People using the service were safeguarded by the complaints and protection procedures that were followed by staff. EVIDENCE: There was a complaints procedure on display and all residents received a copy in their service user’s guide. There had been one complaint to the Commission for Social Care Inspection since the last inspection. The complaint was investigated by the provider and was not upheld. In addition to responding in writing, the provider had arranged a meeting with the complainant to try to resolve their grievances. Residents and relatives who completed surveys and those spoken with during the visit indicated that they knew who to speak to if they had a complaint. One resident said, “If I wasn’t happy I would tell the staff. I think they would try to sort it out.” Staff had access to the Blackburn with Darwen policy and procedure relating to safeguarding adults. The policy specific to the home was clear and concise. There was also a poster displayed on the notice board alerting staff, residents and visitors to the issue of abuse. Some staff had attended the Blackburn with Darwen training; others had covered the topic during induction or NVQ training. The manager also used the Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 17 Blackburn with Darwen training pack as a refresher for staff. The staff spoken with during the inspection were aware of their roles and responsibilities in reporting any allegations to their line manager and outside the home if necessary. Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and well maintained. The standard of décor and furnishings provided residents with a safe, comfortable and homely place to live. EVIDENCE: A tour of the premises evidenced that the home was safe and well maintained. Communal spaces were comfortable and homely and many of the residents’ rooms were personalised with pictures and ornaments. Several areas had been redecorated and had new furnishings since the last inspection. There was an ongoing plan of replacement and refurbishment, which included a complete overhaul of the downstairs bathroom and installation of a special therapy bath. Work was also planned on the garden to raise flower beds to enable people living at the home to do some gardening if they wished. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 19 There was no privacy screening in one of the shared rooms. The manager said that staff would bring a mobile screen from downstairs when they assisted the residents with personal care, but she also intended to discuss the possibility of installing privacy curtains with the provider. Residents, who were asked, said the home was comfortable and they were happy with their rooms. One person said, “It’s very comfortable, nice and warm.” Another said, “My bedroom is small but nice. I have a beautiful view of the bird table and the trees.” At the time of the visit the home was clean and free from unpleasant odours. People who returned surveys and those spoken with during the visit said it was always like that. When asked what the home did well, two relatives included cleanliness in their comment. A number of staff had completed infection control training and the remainder, including housekeeping staff, were due to attend the next course. The infection control guidance on display was not the most recent and the manager was taking steps to obtain the latest best practice guidelines. The laundry was sited in the basement and away from resident areas. It was adequately equipped for the size of the home and on the day of the visit it was tidy and organised. One person remarked that the laundry was quite efficient. Another said, “The laundry is good, you just put your washing out and they take it and bring it back the next day.” Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 good. This judgement has been made using available evidence including a visit to this service. People living at the home were supported by staff who received regular training and supervision. This helped to ensure their needs were understood and met. Recruitment practices did not provide complete safeguards. EVIDENCE: People who completed surveys had mixed responses when asked whether staff were available when they needed them. During the course of the visit most residents said that they thought there were enough staff on duty. The manager and staff also agreed that staffing levels were sufficient. The manager also said that there was the flexibility to increase the numbers if needed. Residents said they got on well with the staff. They described them as pleasant, nice, hard working and polite. Three staff files were inspected. The required pre-employment checks were carried out before people started work at the home and the necessary documents were kept on files. However, there were no records to show that information about previous criminal offences was discussed with the employee. There was no evidence that any potential risk to people living at the home was assessed. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 21 The registration status of registered nurses was checked when they applied for a post and the manager planned to re-introduce a system for checking this annually. Recently employed staff had a record of initial induction which included an introduction to the organisation, orientation of the building and emergency procedures. Staff without qualifications went through an induction programme that met the common induction standards. The manager kept good records of training outcomes and assessments of competency. The AQAA included information about improvements in staff training and supervision. The training matrix showed that a percentage of staff had attended training to update their knowledge and skills in the topics associated with health and safety. For example, moving and handling, basic food hygiene and infection control. The manager stated that others, who were waiting for external courses, had received a degree of refresher training. Methods of recording this in-house training were discussed with the manager. Staff training needs were generally identified through their regular supervision sessions or annual appraisals. Staff had also attended seminars and short courses on a number of topics relevant to the needs of people using the service, for example, diabetes, continence care and pressure relief. 50 of staff held a first aid certificate and 66 of care staff were qualified to NVQ level 2 or above. Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run in the best interests of the people using the service but shortfalls in fire safety training could put residents, staff and visitors at risk. EVIDENCE: A new manager had been appointed since the last inspection. She is a registered nurse and also holds NVQ level 4 in care and management. The manager has a number of years experience of managing care services. In addition to taking short courses she said she kept her management and clinical skills up to date through private study. At the time of the visit the Commission for Social Care Inspection had not received an application to register the manager. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 23 The service held the Blackburn with Darwen enhanced quality assurance award. The systems for seeking the views of people using the service and their families had improved. Surveys had been sent out to everyone living at the home. The manager said she would be notified of any issues requiring immediate action. Other suggestions would be discussed during management meetings and added to the service development plan. There were regular checks and audits to ensure correct procedures and systems were being followed. For example, the manager carried out a monthly audit to ensure care plan reviews took place. The registered person did not act as agent or appointee for anyone living at the home. Although the computerised records were not seen on the day of the visit, the registered person confirmed that there had been no changes in the way residents’ money was handled. Some people were able to manage their own personal allowances and the home held small amounts of money on behalf of others. Transactions were recorded and receipts provided. Computer records were kept and printed copies made available to residents or relatives on request. Servicing and testing of the fire system, equipment and alarms was up to date. Staff had last received fire safety training in October 2006. The manager said that a training aid was on order and the plan was to ensure all staff received instruction. The manager said she discussed fire prevention and procedures during fire drills, which were carried out every few months. However, not all staff had attended a drill in the past year. Certificates were available to evidence maintenance of installations and equipment in the home. There were environmental risk assessments and potentially hazardous items were stored safely. Hollymount Nursing & Residential Care Home DS0000022514.V348108.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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement In order to ensure that people receive medication as instructed by the prescriber, handwritten entries on MAR charts must accurately reflect the information on the prescription. Prescriptions must not be changed without authorisation from the prescriber. Timescale for action 30/11/07 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 OP9 Good Practice Recommendations All handwritten entries on MAR charts should be signed and checked to ensure that instructions are recorded accurately. Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 26 Medication received into the home mid-cycle should be checked and the amount recorded. All medicines packaging should be dated upon opening to enable audits/checks to be carried out. 2. 3. 4. OP9 OP19 OP29 Stocks of controlled drugs should be regularly checked to reduce the risk of mishandling. To protect the privacy and dignity of residents, there should be a privacy screen in each shared bedroom. To protect people living at the home, a risk assessment should be carried out if an employee has previous criminal convictions on their CRB disclosure. In order to safeguard people living and working at the home, the registered person should ensure that all staff have opportunities to be involved in a practice fire drill. 5. OP38 Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Hollymount Nursing & Residential Care Home DS0000022514.V348108.R01.S.doc Version 5.2 Page 28 - 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. 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