Care Home: Holme View

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What the care home does well The manager provides clear leadership and direction to the staff and is readily accessibly to people living in the home and relatives. The staff understand the needs and preferences of all the people who live at the home. Staff have the skills and experience they need to look after people. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 People and their relatives said staff listen to them and act on what they say. Visitors said they are always welcomed. Relatives spoken to said “we have no concern we are made aware of any changes.” We have been involved in the assessment process and care planning and reviews, we have no concern about the home staff,” “all questions are answered with confidence.” The medication procedures are safe and accurate. There is good friendly interaction between people and staff without being overly friendly. Information about people’s history and past experiences is gathered, so that staff have information about the person’s life before they started to use the service. What has improved since the last inspection? We made requirements in the last key inspection report, most of which have been met. One requirement has been carried forward to this report as a recommendation. This is because the home is making good progress in dealing with it. Improvements have been made to the care plans which reflect the care being given and contain more information about people’s preferences. This helps to make sure that care is being given in a consistent way. Risk assessments now contain the necessary actions staff need to take to keep people safe. There are systems in place to monitor people’s weights, with appropriate action taken if there is a change in people’s weight. The home provides people with care and support within the remits of the Mental Capacity Act and Deprivation of Liberty safeguards. Where a decision is made in people’s best interests the decision-making taking proper account of peoples own capacity and includes the involvement of appropriate people such as relatives, advocates, health professional and care staff and a record kept. What the care home could do better: Holme ViewDS0000033613.V377373.R01.S.docVersion 5.2Refurbishment of the home needs to continue to provide people with a safe, comfortable and pleasant place to live. Key inspection report CARE HOMES FOR OLDER PEOPLE Holme View Gillingham Green Holme Wood Bradford BD4 9DT Lead Inspector Valerie Francis Key Unannounced Inspection 23rd July 2009 10:00 DS0000033613.V377373.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holme View Address Gillingham Green Holme Wood Bradford BD4 9DT 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) 01274 681682 01274 687205 City of Bradford Metropolitan District Council Department of Social Services Manager post vacant Care Home 37 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (37), Old age, not falling within any other of places category (37) Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th July 2008 Brief Description of the Service: Holme View is owned by Bradford Metropolitan District Council and provides care for up to thirty-seven people. This includes people with dementia. Holme View is purpose built and the accommodation is arranged around four flats. All of the flats have a lounge and dining area/kitchen, and a communal bathroom and toilets. All bedrooms are for single occupancy. It is in the Holmewood area, on the outskirts of Bradford city centre. There are a few local shops nearby. The home is close to open grassed area which is at the rear of the building. There is a secure fence around the grounds of the home and there is a garden where people can sit out. Inspection reports are available in the home. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is. **2 Stars this means the people who use this service experience good quality outcomes. One inspector made a visit on the 23rd July 2009 at 10:0 am until 5:45pm. The home did not know that this inspection was going to take place. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the people who live there. Before the visit we asked for information from the manager, by sending them a self assessment form, an (AQAA) Annual Quality Assurance Assessment, which gives the home the opportunity to say what they have done since the last key inspection what they are doing to do in the next twelve months and what they could do better. The information includes what policies and procedure they have and when they were last reviewed; when maintenance and safety checks were carried out and by whom. We sent surveys to the home to give to people and staff to find out what their views of the home were. We received ten surveys completed by people and five staff and one volunteer. All their comments are included in the body of this report. The feedback of our findings was given to the manager at the end of the visit. On the 23 July 2009 the full fees ranged from approximately £108.08 to £435. 68 per week with people paying according to their financial assessment. The fee does not cover the cost of hairdressing and private chiropody treatments. The home provides two daily newspapers. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: The manager provides clear leadership and direction to the staff and is readily accessibly to people living in the home and relatives. The staff understand the needs and preferences of all the people who live at the home. Staff have the skills and experience they need to look after people. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 6 People and their relatives said staff listen to them and act on what they say. Visitors said they are always welcomed. Relatives spoken to said “we have no concern we are made aware of any changes.” We have been involved in the assessment process and care planning and reviews, we have no concern about the home staff,” “all questions are answered with confidence.” The medication procedures are safe and accurate. There is good friendly interaction between people and staff without being overly friendly. Information about people’s history and past experiences is gathered, so that staff have information about the person’s life before they started to use the service. What has improved since the last inspection? What they could do better: Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 7 Refurbishment of the home needs to continue to provide people with a safe, comfortable and pleasant place to live. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Holme View DS0000033613.V377373.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 Holme View DS0000033613.V377373.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1& 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with information to enable them to make an informed choice about the home. The admission process is good and includes introductory visits as part of the pre assessment process. EVIDENCE: The home told us they provide prospective people who want to use their service with “information they need to make an informed choice about accessing us as a service provision or not.” Since the last key inspection the home has revised their written information so that all the details are current. Most people indicated in their survey questionnaire that they had received enough information to help them decide if the home was right for them. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 10 All prospective people wanting to use the service have the opportunity to visit the home. This enables the home and the person to assess if their needs will be met. Domiciliary visits are made by staff who have been trained to assess people. We looked at a sample of records and saw that the people’s information is collected from a variety of sources, such as the multi agency assessment. We were told that people and their representative take part in the assessment process where information about them is shared. During our visit we spoke to people and several visiting relatives they all indicated, that they had been involved with the assessment process. Relatives also said they had come to look around before their relative moved in. All the information gathered is used with the home’s own assessment to make a decision that the home can meet the individual care and support needs. We were told that further assessment is made when the person moves into the home as people and staff get to know each other. The home provides respite care and several people who have regular respite care at the home have moved in permanently. Holme View DS0000033613.V377373.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We found that overall there was enough information in care plans for staff to meet people’s care and support needs. Medication practices are safe. EVIDENCE: Everyone who lives at the home has a detailed care plan which outlines their care needs in accordance with their preferences. Since the last key inspection there have been some changes to make sure that each person has a plan which outlines their identified care and support needs. However, people’s care plans are kept in the office separate from the daily log file notes which could mean some needs are overlooked. The home told us that they have improved in the last twelve months by having refresher training for all staff on care planning, to ensure that the needs of people who use their service are recognised and acted upon. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 12 We sampled three people’s care plans and we found that each plan identified their needs with the action staff must take. For people who lack capacity there is an acknowledgement of the Mental Capacity Act and staff are encouraged to support and encourage decision making and remember peoples rights. Care plans are reviewed regularly where and when possible with the involvement of people who use the service, their representatives, any health and social care professionals involved in their care. We were told by visiting relatives that they were involved in the care planning process and review of the care plans and if they had any concern they would speak to the care worker or the manager. They felt that their relative living in the home receives the care they need. People also indicated in the survey that they receive the care and support they need. During our visit we spoke to people who said they were happy with their care and support in the home and staff were always willing to help. The improvements to care plans include clearer healthcare assessments such as an assessment for skin integrity and also included risk assessments, to show that potential risks have been considered and ways to minimise and manage any potential risk. We saw from records that people had their healthcare needs met, there were clear records of General Practitioner visits and the involvement of other healthcare professionals, such as district nurses. During our visit we saw staff assisting people with dignity and respect, for example always asking them their opinion before carrying out a task that involved them. Staff told us in the survey that they have enough support, experience and knowledge to meet the different needs of people who live in the home. Medicines are supplied in the monitored system and appeared to be administered and recorded properly. The home has a list of usual signatures. This is good practice as it helps the home identify staff administering medication. We saw a copy of the draft medication policy. We were told that there is an annual review of medication by the supporting pharmacist used by the home. The manager said she has regular discussions with GPs to discuss stock control for example, the reasons for the omission of repeat prescription, such as paracetamols, when the home knows that they have enough for that person. Holme View DS0000033613.V377373.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 14, 14 & 15. 1People using the service experience Excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported in maintaining contact with family and friends and to make choices. People are provided with a good, varied and nutritious diet that takes account of individual choice. EVIDENCE: We saw that information on people’s history and past experiences is gathered, so that staff have information about the person’s life before they started to use the service. We saw in care files that each person had an activity plan which outlines ways of communicating with people for example by using gestures. People’s care plans identify if they needed one to one support for social activities. The home did not have a designated activity coordinator; activities at the time were carried out by any staff member on duty. The manager said an advert has been made for the post. We saw that staff on each of the floor engaged Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 14 people in various activities, such as reading the newspaper and discussing the news. Holiday arrangements were being made for five people to go on holiday in September. This is good practice. The home has an advocate who visits the home and engages people in activities. People have the opportunity to take part in activities carried out by the staff at the adjoining day centre. We saw and people told us that they took part in activities if they wanted, several people spent their time in their room or sitting in communal areas talking to each other and staff. On the day of our visit the hairdresser was in the home washing and styling the women’s hair, one man had his hair and beard trimmed. We saw that this was made into a social event, giving people time to talk to each other and the hairdresser. The home has a mini bus which is used to take people to and from the day centre and people in the home to local events. The home told us in the AQAA that “we need an activity coordinator to ensure that activities are consistent throughout the unit and are more specialised regarding one to one activities.” We were told that since the last key inspection the home’s management team have learnt to look at the strengths of the staff team with regards to activities, and are now using theses strengths to benefit the service users. There is good community involvement. The home has an established carer committee, who spoke to us at the visit, they spoke of their involvement with the home and how they were given the opportunity to be involved in the home and advocate for their relatives if needed. The home also told us that people’s religious and cultural dietary needs are catered for as agreed on admission. The manager said that a member of staff has been supported to join local black and minority groups, in order that staff have good insight into the different cultural needs of the people and so that they can meet the needs of the people in the geographical areas of the home who may want to use their service. We spoke to the chef, who showed good knowledge of the likes and dislikes of the people living in the home and was clear of the understanding of the special dietary needs of people such as diabetes and the need for fortifying some people’s food and the presentation of the soft diet food. When we visited the home we found it to be relaxed and staff were interacting with people. We saw that the meal time was found to be calm and was unhurried with choice given to everyone. Holme View DS0000033613.V377373.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaint procedure which is available to people and their visitors who know their concerns would be listened to and acted upon. People are protected by the safeguarding procedures. EVIDENCE: The manager told us “we operate an open door policy on complaints,” which they use” to improve their service delivery, and aims to build relationships for all to access our service provision.” The home provides people and their representatives with a copy of the complaint procedure and a copy is displayed in the home for easy access to anyone wanting to use it. We looked at the way complaints and safeguarding issues are handled by the home and we found that a log is kept of all complaints and safeguarding matters raised. We saw that complaints are investigated and letter of response sent to the complainant, in accordance with the procedure. We also saw that all allegations of abuse are handled according to the procedure and all referrals made to the safeguarding unit and the Commission. We looked at the staff training records and although we found that all staff have had training in adult protection not all had had updated training. The Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 16 manager said she has started training for staff on the Mental Capacity Act, and Deprivation of Liberty safeguards. We saw some good information with regards to people’s right and choices. The assessment processes in place make sure people’s capacity is taken into consideration at all times. Returned surveys from people indicated that they had someone they can speak to if they were not happy. However, most people were not aware how to make a formal complaint. The three staff who completed the survey, indicated that they knew what to do if anyone had any concerns about the home. During our discussion with people, visitors and staff they all said if they had any concern they would speak to a member of staff or the manager, and know that it would be taken seriously and dealt with. All staff had been made aware of the ‘whistle blowing’ policy to be used if they suspect abuse or see example of bad practice. It was apparent from discussion with staff that they had no concern about using the procedure to report any issue of abuse. Holme View DS0000033613.V377373.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 29, 23, 25 & 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, comfortable and well maintained environment. EVIDENCE: During our visit and our walk around the building we found that generally the home was well maintained. Since the last key inspection, several areas of the home have been refurbished; the corridors and lounge areas have been redecorated and newly furnished. We were told in the AQAA that the plans for the next twelve months are to continue with the refurbishment of the home, concentration on bedrooms by renew decorations and furnishings. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 18 We found that all areas include signs to help people get to the place they want. For example all bedrooms have a photo of the occupant helping people to find their own rooms and bathroom and toilets have photos of a bath and toilet. This helps to orientate people and helps them to maintain and manage independently for longer. Electrical fans in all areas needed cleaning, to eliminate the risk of fire. We were told that there are plans in place to have another laundry upstairs. The laundry was clean, tidy and well organised. There is sluice washer provided. The manager said they plan to continue with infection control training for all new and existing staff who has not undertaken the training. During the visit no offensive smell was observed. People and their visitors said that the home was always fresh and clean. Holme View DS0000033613.V377373.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by staff who are trained to meet their needs. EVIDENCE: On the day we visited the home we were told that there were some staff shortages, and a member of care staff came in to cover a vacancy. The rota showed that there should have been seven care staff which included two officers in the morning, six staff in the afternoon and three staff at night one of whom is a senior care worker. People and their visitors told us that there are staff shortage at times, which “sometimes has an impact where they are dashing around.” Despite this staff indicated in the completed surveys that usually there are enough staff to meet the individual needs of all the people in the home. During our visit we saw that staff were relaxed and carried out their work in an unhurried way. We were told in the AQAA that “the skill mix of the staff group is relevant to the needs of the service users. Domestic hours are fully staffed, and we ensure and implement a robust cleaning schedule.” “All recruitment and selection is completed in line with equal opportunity and recruitment legislation.” “Two Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 20 written references are always obtained before a (CRB) Criminal Record Bureau check is requested, and only after a satisfactory CRB check is received is the individual is offered employment.” All new starters receive a contract of employment, which outline the terms and conditions of their employment and service. Volunteers to the service are employed through the Social Service Volunteering scheme and this is only after a satisfactory CRB. We looked at three staff files and saw that all the required checks are completed before staff start work at the home. The home have over 50 of their staff with an NVQ National Vocational Qualification level 2 and some have started NVQ level 3. All staff undertake induction training. All staff have a development plan which they discuss during their one to one supervision. The training plans include training on the Mental Capacity Act, moving and handling, food hygiene, fire safety, infection control and risk assessment. The manager said plans were in place for two further management team members to undertake the role of NVQ assessor to speed up the productivity in this area, and to continue to develop the staff with the use of in house training. Holme View DS0000033613.V377373.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is well organised and practices promote and safeguard the health and wellbeing of people living at the home. EVIDENCE: The home has not had a registered manager for some time. However, the manager said the post had been advertised and an interview had been arranged. The temporary manager has been at the home for nine months, she has twenty years experience of working with older people which includes twelve years of training and management experience. She hold the NVQ 4 and Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 22 Registered manager award. This confirms she has the skills and experience to manage the home. The manager said she has an open door management approach. The manager is committed to running the home in the best interest of the people living there. . People told us “the manager has made good changes in the time she has been there.” Visitors said they always feel welcome and the manager is available to discuss any issue they may have. There is a good audit trail of money kept on behalf of people and all records with receipts of purchase are available. There are signature of all staff involve in the transaction. The manager said an annual quality audit is made and every July questionnaires are sent to people, relatives and all involved in the home. The outcome is then written up by the manager and displayed on the home’s notice board, which is accessible to all. There is a monthly visit made by a volunteer who looks at the environment and speaks to three staff and 3 people living in the home. Staff have two monthly one to one where staff can discuss their personal development and any issues. The manager has monthly supervision with her line manager to the home. There are regular meetings held for all staff, management, and designated staff on each wing have a monthly meeting We were told by visitors and staff that the manager is approachable and always willing to listen All accidents are monitored monthly to ensure that there was not a pattern. The home had a fire safety check carried out by the West Yorkshire Fire Service and a recommendation had been made for the roof void to be secure, the timescale given is October 2009. All personal information is stored in lockable secure cabinets We saw records that all the required health and safety check have been done within the required timescales. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 23 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 3 X X X X 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 3 X X 3 X 3 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 2 X 3 X 3 X X 3 Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 24 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. 1. Refer to Standard OP19 Good Practice Recommendations To make the home comfortable and safe and to meet people’s needs, the programme of redecoration should continue around the home. 2. OP7 People’s care plans should be readily accessible to staff with their daily notes, to make sure that people’s care needs are not overlooked. Holme View DS0000033613.V377373.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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