Care Home: Holmdale House

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What the care home does well What has improved since the last inspection? Since the previous inspection in January 2007 the owners have re-registered the home as a Limited Company and an additional four bedrooms, all with ensuite facilities have been registered. The home has replaced carpets in all the communal rooms and the manager stated that all easy chairs are to be replaced over the coming months. The home has also redesigned and re-laid the patio area and installed a safety rail in the garden. The home continues its planned programme of redecoration and maintenance. The home has fully complied with the requirements made following the inspection in January 2007. Following consultation with the Isle of Wight fire service, new keypad locks on external doors should ensure that people who wish to go out are able to do so. All bedroom doors now have a lock and people are offered the choice of a key. People confirmed this to the inspector during discussions. New doors and locks have been fitted to the bathroom and toilets. The home has purchased a quality monitoring system that will ensure that people who live at the home and other stakeholders are consulted in a formal manner as to the service provided. What the care home could do better: There were no requirements or recommendations made following this key inspection. CARE HOMES FOR OLDER PEOPLE Holmdale House Main Road Havenstreet Ryde Isle Of Wight PO33 4DP Lead Inspector Janet Ktomi Unannounced Inspection 21st September 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 Holmdale House DS0000070442.V352026.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. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmdale House Address Main Road Havenstreet Ryde Isle Of Wight PO33 4DP 01983 882002 01983 884493 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) Holmdale House Ltd Mrs Mahin Dokht Smyth and Mr Michael James Smyth Care Home 31 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 31. Date of last inspection 23rd January 2007 Brief Description of the Service: Holmdale House is a large detached property on the main road in the village of Havenstreet. The nearest town is Ryde. The accommodation is on three levels. The home has a passenger lift and stair lifts in order to access all levels. The home is registered to provide accommodation and care for up to 31 people over the age of 65 years who may or may not have dementia. The home has appropriate communal and bathing facilities. Most bedrooms are for single occupancy, some with ensuite facilities and most having rural views. The home is sited in the village and close to all local amenities. There is a car park to the side of the home. The home is owned by Holmdale House Ltd and jointly managed by Mr and Mrs Smyth. The scale of charges is up to £462.00 per week. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information gained prior to and during an unannounced visit to the home undertaken on the 21st September 2007. All core standards and a number of additional standards were assessed. The visit to the home was undertaken by one inspector and lasted approximately six and a half hours commencing at 09.30 am and being completed at 4 p.m. The inspector was able to spend time with one of the registered managers and staff on duty and was provided with free access to all areas of the home, documentation requested, visitors and people who live at the home. Prior to the visit the manager completed an annual quality assurance questionnaire, information from which is included in this report. Comment cards were returned from one care manager and one GP. The inspector met with a visiting health professional during her visit to the home. Comment cards were sent to the home for distribution to people who live at the home and their relatives/visitors. Two comment cards were received from people who live at the home and two relative responses were received. Information was also gained from the link inspector and the home’s file containing notifications of incidents in the home. During the visit to the home the inspector was able to meet with and talk to many of the people who live at the home, staff on duty and two visitors. What the service does well: What has improved since the last inspection? Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 6 Since the previous inspection in January 2007 the owners have re-registered the home as a Limited Company and an additional four bedrooms, all with ensuite facilities have been registered. The home has replaced carpets in all the communal rooms and the manager stated that all easy chairs are to be replaced over the coming months. The home has also redesigned and re-laid the patio area and installed a safety rail in the garden. The home continues its planned programme of redecoration and maintenance. The home has fully complied with the requirements made following the inspection in January 2007. Following consultation with the Isle of Wight fire service, new keypad locks on external doors should ensure that people who wish to go out are able to do so. All bedroom doors now have a lock and people are offered the choice of a key. People confirmed this to the inspector during discussions. New doors and locks have been fitted to the bathroom and toilets. The home has purchased a quality monitoring system that will ensure that people who live at the home and other stakeholders are consulted in a formal manner as to the service provided. What they could do better: 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. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 7 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 Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 8 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, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people are assessed prior to moving into the home to determine that their individual needs can be fully met. People, or their representatives, are able to visit the home prior to admission to assess the quality, facilities and suitability of the home. Standard 6 is not applicable, as the home does not provide intermediate care. EVIDENCE: The registered manager explained the homes admission procedure and three pre-admission assessments were viewed. One of the two joint registered managers undertakes pre-admission assessments on all prospective people. The registered manager stated that a member of senior care staff is also part of the pre-admission assessment and is involved in the decision as to whether to offer a place at the home. Care staff confirmed this. The home has an assessment tool that covers all the relevant areas necessary for the home to Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 9 decide if it is able to meet a prospective persons needs. The registered manager was clear about the level of care needs the home can accommodate and consideration would be given as to the available room when completing an assessment as a few bedrooms can only be accessed via a short flight of stairs. The registered manager stated that ideally the person would visit the home prior to deciding to move in however when this was not practicable relatives or representatives are invited to visit the home and view the available room. The registered manager stated in the homes annual quality assurance assessment that it routinely contacts GP’s and other relevant professionals before an admission to gain feedback about the suitability of the admission. One comment card was received from a care manager who stated that the homes ‘care services assessment arrangements always ensures that accurate information is gathered and the right service is planned and given to individuals’. Two comment cards were received from people who live at the home. These both stated that they had received a contract and that they had received enough information about the home before they moved in. Two comment cards were also received from relatives of people who live at the home who stated they had received enough information about the home. The inspector was able to meet a relative visiting the home on the day of the unannounced visit who confirmed that she had received appropriate written information about the home. The registered manager stated that the statement of purpose and service users guide was being re-written to reflect that the home was now a limited company and had registered an additional four bedrooms (three single and one for twin occupation). Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care. Medication is appropriately stored, however the Medication Administration Records contained a number of gaps. People are treated with respect. EVIDENCE: The inspector viewed four care plans for new and existing people. Care plans are individual and relevant to the needs of people. All care plans followed a similar format and are in an assessable format for care staff and people should they wish to see their care plans. Care plans were seen to be reviewed monthly or if needs changed significantly. People living at the home confirmed that they were aware that the staff maintained written records however they were not that interested in viewing their care plans. Within all care plans were comprehensive individual moving and handling assessments, which clearly indicated how people should be supported with Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 11 moving and handling. Also in care plans were risk assessments in relation to falls, information about nutritional needs, a hazard analysis and specific risk assessments relating to individual risk. Training records confirmed that staff have undertaken manual handling training. Appropriate manual handling equipment was seen during a tour of the home. The inspector was able to meet many of the people living at the home. They all stated that they felt very well cared for; others whose level of disability made conversation difficult appeared comfortable, relaxed and well cared for. The inspector spoke with two visitors’ who stated that they were very happy with the level of care their relative received. Comment cards were received from two relatives, both stated that medical and care needs were always met. One added ‘my mother has said that she couldn’t be better looked after’. No concerns about the level of care were raised in these comment cards. Comment cards were also received from two of the people who live at the home who stating that they always/usually receive the care and support they require. One adding ‘staff are always kind and helpful’. People the inspector spoke with during her visit to the home made similar comments. The care manager who completed a comment card stated ‘in my personal opinion I have always felt the managers offer all the appropriate support to the clients’. People living at the home stated that they felt well looked after and that if they were ill the home would organise for a doctor to visit them. Comment cards from people living at the home stated that they always received the medical care they required. Comment cards were received from one GP who stated that the home seeks advice and acts upon it to improve and manage people’s health care needs and that individuals health care needs are always met by the home. The GP also stated that they felt the staff had the necessary skills to meet people’s needs. The care manager who returned a comment card also stated that peoples healthcare needs are always met. The inspector spoke with a visiting health professional who was very complementary of the care provided to people living at the home. One of the joint registered managers is a qualified nurse and the home has employed a qualified nurse as the deputy manager. Discussions with the manager during the inspection visit indicated that he knew how to contact external professionals and when this should be done. Records seen during the inspectors visit indicated that health professionals are appropriately consulted. The home invites various health and social care professionals to give a talk following staff meetings. These have included care planning and older persons mental health issues. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 12 The inspector undertook a tour of the home with the manager and was therefore able to meet some people who had chosen to remain in their bedrooms. Care staff stated that they felt they had enough time to meet people’s health and personal care needs. Discussions with and comment cards received from people confirmed that staff are available when required. Only senior staff who have undertaken additional training and been deemed competent administer medication in the home. All medication was seen to be stored in a secure locked facility. The home uses a pre-dispensed blister system where possible. The Medication administration records were viewed and found to contain a number of gaps where it was not evident if medication had been administered or not. The registered manager undertook an audit of these during the inspection and stated that he would be discussing this with the staff concerned. In addition the homes deputy manager, who is a qualified nurse, will in future be undertaking a weekly audit of the medication administration records. The registered manager stated that further medications training is planned and this would also highlight the need for full and accurate recording. Comment cards received from people confirmed that staff listen and act on what they say. People and relatives the inspectors spoke with confirmed that staff treat them with respect and that their privacy is maintained during personal care. During the inspectors visit staff were observed to treat people with respect, this was also confirmed by professional comment cards received. The care manager stating ‘on discussing this with my clients – they were extremely happy on these issues. On visiting I have always been asked if my clients would like to be moved to a private area to converse’. The GP confirmed that the home always respects individual’s privacy and dignity and responds to individuals’ different needs. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Family and friends are able to visit. People receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. People and relatives confirmed to the inspector that they are able to choose where in the home they spend their day, many were seen to spend time in the homes lounge with others remaining in their bedrooms. People were observed being asked where they wanted to have their meals, most people choosing to eat in the dining room. People confirmed to the inspector that they are given choice over their meals with options being chosen on a daily basis. Bedrooms seen contained personal items brought into the home. Care plans and assessments include information about leisure Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 14 activities, catering and religious needs. People stated that they are able to get up and go to bed at times of their choosing. The home stated within the annual quality assurance assessment that a range of entertainments and activities are organised including outings, coffee mornings, garden fetes and visiting entertainers. It also identified that the home had a good relationship with the local church and when they have communion in the home a number of people from the village join them and stay to socialise afterwards. People living at the home confirmed this to the inspector. The home has access to a community minibus with wheelchair access for outings to places selected by the people living at the home. Twice a week the home has visiting entertainers with a musical theme, one includes a reminiscence style quiz with keyboard music and the other brings a variety of hand held instruments for people to join a karaoke style music afternoon. People were positive about the activities the home provides. The inspector was able to meet two visitors who agreed with statements in the comment cards also received from relatives that they are able to visit at any time and kept informed about issues affecting their relative. The home has a large dining room where many people choose to have their meals. People stated that the food is always good, ‘very good’, and choice provided. Relatives confirmed that they are able to have meals at the home if they wished and that their relatives appeared to enjoy their food. The inspector was present for the main lunchtime meal. The food was well presented and people stated it tasted nice. Drinks and snacks are also available throughout the day with people confirming this as well as the inspector observing people being given morning and afternoon hot drinks and biscuits/home made cakes. The need for special diets or supplements is recorded pre-admission. The home has a good-sized kitchen. The home has recently been inspected by the environmental health department and awarded the maximum five stars for kitchen cleanliness. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. EVIDENCE: The homes complaints procedure is included in the service users guide provided to all prospective admissions or their relatives. Within the entrance hall is a notice providing further information as to what to do if a person or visitor has any concerns or complaints. Care staff stated that they would try to resolve any issues raised by people or relatives, if they were unable to do so they would inform one of the registered managers. The annual quality assurance assessment completed by the home prior to the inspection stated that ‘because of our informal approach of seeking service users views daily, we are able to address any concerns quickly, before we would consider them to have escalated into a complaint. Because of this we have not had any formal complaints in the recent months’. No complaints have been received about the service to the commission. People and relatives the inspector spoke with also stated that although they had no concerns or complaints they would feel able to raise any issues with staff or one of the managers. Comment cards from relatives stated that they Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 16 knew how to make a complaint and the home had responded appropriately if any issues had been raised. This was also the view of the care manager who completed a comment card who stated ‘issues/concerns have always been acted upon, consulted with and resolved immediately they have been raised.’ Care staff confirmed that they have attended safeguarding adults training and were clear as to the action they should take should they suspect that a person might have been abused. The home acted appropriately following an incident between two people who live at the home, consulting the relevant external professionals and taking action to ensure that the situation would not re-occur. The homes policies and procedures in respect of recruitment and people’s personal finances should ensure that unsuitable people are not employed at the home and that people will not be financially abused. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 17 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. People live in a clean, safe, well-maintained environment that meets their individual and collective needs. EVIDENCE: The manager showed the inspector round the home (as she had not previously visited Homedale House) and the inspector was then able to move independently around the home. Since the previous inspection the home has completed internal adaptations and registered four new bedrooms, all with ensuite facilities. The home has a part time maintenance person and housekeeping staff. Overall the home is clean and has a planned programme of maintenance. The home is an adapted older building therefore it is restricted as to changes it can make to address issues such as short flights of stairs to access some bedrooms. The registered manager stated that consideration to Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 18 this is given when assessing and considering new people for the home. Bedrooms are of various sizes and one person informed the inspector that that she was very happy with her new bedroom that had en-suite facilities. Bedrooms seen contained various items of personal furniture and possessions brought into the home by the rooms’ occupant. The home has a shaft lift, dining room, additional sitting areas, pleasant accessible gardens and a bright lounge. Most bedrooms are for single occupancy with the registered manager stating that people are only admitted to twin rooms if they are happy with this arrangement. Some rooms have ensuite facilities. People stated they were happy with their bedrooms and communal facilities. Assisted bathing facilities are available and WC’s are located close by the lounge/dining room. Since the previous inspection in January 2007 the home has replaced carpets in all the communal rooms and the manager stated that all easy chairs are to be replaced over the coming months. The inspector noted that chairs of various heights were available in the lounge. The home has also redesigned and re-laid the patio area and installed a safety rail in the garden. Moving and handling equipment was seen during the inspection visit with care staff confirming that they had the necessary equipment to meet people’s needs. Following the previous inspection two requirements were made in respect of bedroom door locks and locking the inner lobby door (fire exit). The registered manager explained the action the home has taken following consultation with the Isle of Wight fire service. The new keypad locks should ensure that people who wish to go out, and are able to do so, are issued with the keypad number. All bedroom doors were seen to have a lock and people are offered the choice of a key. People confirmed this to the inspector during discussions. The inspector also viewed the new doors and locks that have been fitted to the bathroom and toilets as required following the previous inspection. The comment cards from people living at the home both confirmed that the home is always fresh and clean. The home employs housekeepers who stated that they have sufficient time to complete their daily and weekly cleaning schedules. The home has a sluice and laundry facility that is appropriate for the size of the home. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 19 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. The home employs appropriate numbers of care and ancillary staff that ensure that peoples needs are met. Staff receive the necessary training and above fifty per cent of care staff have NVQ in Care of at least level 2. EVIDENCE: All comment cards, from people who live at the home, relatives and professionals were positive about care staff. One person who lives at the home stated in the comment card ‘ staff are always kind and helpful and always spare the time to listen’. One relative commented ‘staff excellent’, the other staff well trained, everyone is treated equally’ and added ‘staff cannot do enough for my mother’s comfort and every request/comment is treated with respect’. The GP stated that ‘staff always have the right skills and experience to support individuals social and health needs’. Discussions with people during the visit to the home confirmed the above opinions. Duty rotas were seen during the visit to the home. Duty rotas stated that five care staff (one senior), and a cook, kitchen assistant and cleaner, are provided in the morning; four care and a cook in the afternoon and three care (one senior) in the evening between 6 and 10pm. Two awake care staff are provided Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 20 at night. In addition one or both of the homes registered managers is available during weekdays, and often at weekends, and the homes deputy who is a qualified nurse has supernumerary time during the week. People and visitors stated that there are sufficient staff on duty. During the inspectors visit staff on duty corresponded to those on the duty rota. Care staff stated that they generally have sufficient time to meet people’s needs and throughout the inspection care staff appeared to have time to meet people’s needs. The manager confirmed that an on call support is provided when neither of the managers is at the home. The manager provided training and qualification information during the inspection and in the homes annual quality assurance assessment. The home has a high number of care staff with an NVQ of at least level 2 with many having a level three qualification. Additional care staff are to undertake NVQ training. Discussions with care staff confirmed that many on duty had NVQ qualifications in care. The registered manager identified in the homes annual quality assurance assessment that the home promotes staff training. The inspector viewed training certificates in staff files and staff stated that they have regular opportunities for training both in house (guest speakers are invited to staff meetings) and external training such as at the local college. As previously identified external professionals and people who live at the home felt that staff have the necessary skills and knowledge to meet their needs. Care staff confirmed that they were not expected to undertake tasks outside their level of knowledge or skill. The home has a consistent staff team. The recruitment records for the two newest staff were viewed. These contained all the required information and confirmed that all staff are fully checked including references, CRB and POVA checks prior to commencing employment at the home. The homes recruitment procedures should ensure that unsuitable people are not employed at the home. The manager explained the homes induction procedure and showed the inspector the induction booklet in use at the home for care staff. Staff files contained evidence of appropriate induction. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 21 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, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The joint registered managers have the necessary skills and experience to ensure that the home is appropriately managed and run in the best interests of the people who live there. People’s financial interests are safeguarded. Records are generally well maintained and stored securely. The health, safety and welfare of people and staff are promoted. EVIDENCE: The home is jointly managed by the homes two registered managers, one of whom was present on the day of the unannounced visit to the home. Both Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 22 managers have the Registered Managers Award and one is a qualified Nurse. They have jointly owned and managed the home for nineteen years. Discussions with the manager who was present indicated that they have divided some of the management responsibilities and are aware of each other’s roles. The manager identified in the homes annual quality assurance assessment that additional staff also have the Registered Managers Award and specific responsibilities have been delegated to some of them. The home also has a deputy manager who is also a qualified nurse. Care staff, visitors and people who live at the home stated that they felt able to approach either of the managers should they have any issues or concerns. The registered managers identified in their annual quality assurance assessment that the home needs to formalise some of the quality monitoring systems in use in the home. They identified that these are often informal and not recorded. The inspector was shown the proposed quality monitoring system that the home has purchased and this will ensure that people who live at the home and other stakeholders are consulted in a formal manner as to the service provided. The annual quality assurance assessment was well completed and indicated that the managers were able to consider the service they provide and how changes and improvements could be made to improve the service provided. The home does not does not act as appointee for anyone. The home invoices people for any additional services (hairdressing, chiropody or toiletries) supplied. One relative spoken too confirmed that she was fully aware of what the additional services were and that invoices were clear as to what was being charged for. There were no previous issues re staff supervision therefore this standard was not assessed. Care staff stated that they felt appropriately supported with an on call system in place when neither manager is at the home. Various records were viewed during the inspectors visit. All records were appropriately stored with access only available to people who should have access. With the exception of the Medication administration records discussed in an earlier section of this report records were seen to be well maintained. During the inspectors visit there were no concerns in respect of health and safety identified. In the annual quality assurance assessment the home identified that an external company has undertaken a health and safety audit of the home and were satisfied with the health and safety practises in the home. This company provides a health and safety manual for staff specifically designed to reflect the practises and needs of the home. The home is well maintained and clean, with staff having relevant training to meet people’s needs. Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 23 Holmdale House DS0000070442.V352026.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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 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 3 X 3 X 2 3 Holmdale House DS0000070442.V352026.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. Standard Regulation Requirement Timescale for action 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 Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Holmdale House DS0000070442.V352026.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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