Care Home: Holmfield

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What the care home does well Holmfield is managed in the best interests of the people using the service. The management team and care staff are committed to making continual improvements in the way the service is provided. The views of people using the service are important to staff and this information is used to monitor how well they are doing in meeting individuals` needs. One person completing a survey said, "The staff are always available to speak to me, either on the phone or in person. Nothing is too much trouble for them. All the staff are first class." People enquiring about the home are provided with a comprehensive information pack and are encouraged to visit the home. This enables them to reach an informed decision on whether the home will be the right place for them to live. The following comment was made in a survey returned to the Commission, "I went to see the home and was taken around it. The lady gave me full information before my mother moved in." Daily activities and trips to the theatre provide interest and stimulation for people living in the home and this was commended as an example of best practice. Similarly, the high standard of catering, commended at the last inspection, has been maintained and further improved. Issues relating to concerns, complaints and safeguarding older people are managed well and this keeps people living in the home safe. What has improved since the last inspection? The seven requirements and eleven recommendations made at the last inspection had been addressed demonstrating that the wellbeing of people living in the home was given priority. Staff had worked hard to improve the system in place for the administration of medication. It was pleasing that they were rewarded with a commendation in this area for exceeding the minimum standard expected. Significant improvements had been made in monitoring systems and staff performance and health and safety practice and procedures. Environmental reorganisation had resulted in increased office space and the provision of a treatment room used by the district nursing team. This enhanced peoples` rights to privacy and dignity within the home. Considerable capital expenditure had been invested to provide improvements to the environment, such as redecoration and the replacement of furniture and equipment. The following comment was made in a survey "Lots of improvements are taking place now that Age Concern are there. Everywhere is clean, cheerful and bright and getting better all the time." Improvements had also been made in the area of care planning. What the care home could do better: One immediate requirement and eleven good practice recommendations were made during the inspection visit. A bedroom door was found to be not fully closing into its rebate. This placed the two people accommodated in the room at serious risk of harm from smoke inhalation in the event of a fire. It was reassuring to learn that the problem had been addressed the following day. Several recommendations were made in relation to the way information was recorded in care plans and this was determined to be a staff training and development need. Staff should be more vigilant in recognising changes in service users health and welfare, particularly in relation to significant weight loss. Additionally, assessment and care planning processes should incorporate bereavement and loss as a need to ensure that individuals` emotional, psychological and mental health needs can be met. Life histories developed with people living in the home had been temporarily removed to another location for updating. Personal and confidential information belonging to service users should be held securely in the home to comply with data protection legislation.In addition to their caring duties, care staff undertook laundry tasks and it was noticed that they were constantly interrupted by having to let a steady stream of visitors in and out of the home. To ensure that people living in the home receive continuity of care it was recommended that the provider consider employing laundry and administration/reception support at busy times of the day. There was a build up of fluff and dust behind laundry equipment that should be removed and the laundry would benefit from redecoration. Infection control training should be provided for staff to ensure that the health and welfare of people living in the home is protected. CARE HOMES FOR OLDER PEOPLE Holmfield 4 Darley Avenue West Didsbury Manchester M20 2XF Lead Inspector Val Bell Unannounced Inspection 10th April 2008 10:04 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 Holmfield DS0000067934.V362012.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. Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmfield Address 4 Darley Avenue West Didsbury Manchester M20 2XF 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) 0161 434 1480 F/P 0161 434 1480 Age Concern Manchester Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC. To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age not falling within any other category - Code OP The maximum number of people who can be accommodated is: 29 Date of last inspection 31st July 2007 Brief Description of the Service: Holmfield Care Home is registered to provide personal care for up to 32 older people, although the home currently provides 3 double and 23 single bedrooms to accommodate 29 people. The service is owned and managed by Age Concern Manchester. The home is a large detached building in West Didsbury, south of Manchester City Centre and is situated in a residential area close to local shops and community facilities. Public transport links into Manchester and Stockport City Centres are within easy walking distance. The home is set in extensive and well-maintained grounds and a gardener is employed to ensure that residents are able to enjoy the garden when the weather is good. Safe wheelchair access is provided at the back of the building. The home has 3 lounge areas. Visitors can see residents in privacy in their bedrooms or in the lounge areas. Bedrooms are fitted with emergency call systems and hand washbasins. Residents are encouraged to bring their own furniture, photographs and personal things to make their bedrooms homely. Bathroom and toilet facilities are sufficient to meet residents’ needs and are located close to bedrooms and communal areas. The fees charged by the home are £373:09 per week for a shared room and £388:54 per week for a single room. Holmfield DS0000067934.V362012.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 star. This means the people who use this service experience good quality outcomes. This was a key inspection, which included a site visit to the home. This visit was unannounced which means the manager was not informed beforehand that we were coming to inspect. During the visit we spent time talking to five people living in the home, three members of staff on duty and management. An Annual Quality Assurance Assessment (AQAA), which is a self-assessment document, had been completed and returned to us by the manager prior to this visit. One member of the staff team and six people living in the home completed satisfaction surveys prior to the visit. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: Holmfield is managed in the best interests of the people using the service. The management team and care staff are committed to making continual improvements in the way the service is provided. The views of people using the service are important to staff and this information is used to monitor how well they are doing in meeting individuals’ needs. One person completing a survey said, “The staff are always available to speak to me, either on the phone or in person. Nothing is too much trouble for them. All the staff are first class.” People enquiring about the home are provided with a comprehensive information pack and are encouraged to visit the home. This enables them to reach an informed decision on whether the home will be the right place for them to live. The following comment was made in a survey returned to the Commission, “I went to see the home and was taken around it. The lady gave me full information before my mother moved in.” Daily activities and trips to the theatre provide interest and stimulation for people living in the home and this was commended as an example of best practice. Similarly, the high standard of catering, commended at the last inspection, has been maintained and further improved. Issues relating to concerns, complaints and safeguarding older people are managed well and this keeps people living in the home safe. Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: One immediate requirement and eleven good practice recommendations were made during the inspection visit. A bedroom door was found to be not fully closing into its rebate. This placed the two people accommodated in the room at serious risk of harm from smoke inhalation in the event of a fire. It was reassuring to learn that the problem had been addressed the following day. Several recommendations were made in relation to the way information was recorded in care plans and this was determined to be a staff training and development need. Staff should be more vigilant in recognising changes in service users health and welfare, particularly in relation to significant weight loss. Additionally, assessment and care planning processes should incorporate bereavement and loss as a need to ensure that individuals’ emotional, psychological and mental health needs can be met. Life histories developed with people living in the home had been temporarily removed to another location for updating. Personal and confidential information belonging to service users should be held securely in the home to comply with data protection legislation. Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 7 In addition to their caring duties, care staff undertook laundry tasks and it was noticed that they were constantly interrupted by having to let a steady stream of visitors in and out of the home. To ensure that people living in the home receive continuity of care it was recommended that the provider consider employing laundry and administration/reception support at busy times of the day. There was a build up of fluff and dust behind laundry equipment that should be removed and the laundry would benefit from redecoration. Infection control training should be provided for staff to ensure that the health and welfare of people living in the home is protected. 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. Holmfield DS0000067934.V362012.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 Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. Prior to admission people receive an assessment of their needs and written information that helps them to decide if the home will be the right place for them to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A comprehensive information pack is presented to people enquiring about this home. This helps people to make informed decisions on whether the home will be an appropriate place to live. Prospective residents are encouraged to visit the home to have a look round, have a meal and join in the activities that are provided daily. This provides the opportunity to meet staff and other people living in the home and to ask questions about how the home is run. Before a decision is taken to move into the home, each person has a thorough assessment of their needs to determine if the service will be able to meet their needs in a way that suits the individual. The six people that returned surveys to the Commission confirmed this. Comments included, “I went to see the Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 10 home and was taken around it. The lady gave me full information before my mother moved in” and “Visited the home twice. The manager came to visit my mother prior to her going there.” The home does not offer an intermediate care service. Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. Staff work hard to meet peoples personal and healthcare needs in a way that promotes dignity and suits individual choice and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans had been drawn up from information provided in the assessments of need and from conversations with people admitted and their representatives. The standard of care planning had improved since the last inspection, with identified areas of risk, such as falls, being assessed and managed well. Three care plans were examined in detail. It was evident that people using this service had been asked about their preferences in the way their care should be provided. This enabled people to make choices about their lifestyles, such as how their personal and healthcare needs should be met and the daily routines that they preferred. Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 12 Individuals’ healthcare needs were generally being met, with evidence of referrals to general practitioners and other healthcare professionals. However, one of the people being case-tracked had lost twelve pounds in weight over a period of thirteen months. Although staff had signed monthly reviews of this person’s care plan, no action had been taken to determine the cause of the weight loss. Similarly, a second person had gained eight pounds in weight since her admission eleven weeks previously. This person’s care plan recorded that she was at risk of falls and in this context, excessive weight gain may increase this risk. Furthermore, one of the people case-tracked had suffered a family bereavement prior to admission to the home. This had been recorded in the care manager assessment of need, but had not been taken into consideration by the in-house assessment or the care planning processes. This is critical information that may affect a person’s wellbeing and should be considered when reassessing this person’s needs. Weight and malnutrition screening records contained a confusing mix of both imperial and metric weight measurements. The person in charge agreed to address these issues promptly. A telephone call to the home following the inspection visit confirmed that relevant steps had been taken to maintain the welfare of these two people. Furthermore, review records lacked the detail to provide evidence that sufficient attention was paid to assessing progress made each month. A typical review record stated, ‘No change required.’ These records should detail the specific progress made since the previous review. The third care plan stated that the person was confined to bed and under the direct care of the district nursing team. Instructions had been written down for care staff to provide regular positional changes and to record the person’s fluid intake in order to minimise the risk of developing pressure ulcers. The care plan stated that positional change and fluid intake charts were to be held in the person’s bedroom for completion by staff. There was no evidence of this, although care staff had made some entries in the person’s daily records. There was room for improvement in the quality of information in daily records. A typical entry was, ‘Seems fine, ate tea, sat in lounge, no problems.’ These records should record the actual care provided according to the care plans that are in place. This was discussed with the person in charge and the area manager who agreed that this was a training and development need. The area manager confirmed her commitment to developing staff skills in this area. Further recommendations were made to reinstate information sheets in care plans, listing people’s personal information such as next of kin, date of birth, religion etc. and separate records of the outcome of health appointments. Significant improvements had been made to the way medication was administered to people living in the home. Records belonging to the three people case-tracked were found to be accurate and up to date. Reasons for non-administration of medication had been clearly recorded and there was evidence that regular monitoring was being done by senior staff. Detailed Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 13 medication care plans were held in the medication records, providing staff with clear guidance. This exceeded the minimum standard expected and was commended as an example of best practice. Staff were observed to interact respectfully with people living in the home and this was confirmed in conversation with people during the visit. Staff are careful to provide personal care in private to maintain the dignity of people living in the home. Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. People living in the home are provided with stimulating and interesting activities and wholesome diets that meet their preferences and assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The person-centred approach relating to activities provided for people living in the home had been maintained since the last inspection and further improved by offering more one-to-one activities for people that prefer this. However, the life history work that had been developed for individuals was not available for inspection during the site visit. These records had been moved to an Age Concern day centre for updating. Personal and confidential information should be held securely in the home and be available to people using this service at all times. It was pleasing to note the links that have been made between the home and The Royal Exchange Theatre and adult education. This has further developed the range of opportunities for people living in the home to try new experiences Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 15 and to form new relationships outside the home. This was commended as an area of best practice. Conversations with four people living in the home confirmed that their visitors are made welcome. One person said, “Staff welcome my family and always offer them a cup of tea.” The self-assessment document completed by the manager provided the following information; ‘All residents are encouraged and supported to maintain links with their family and friends.’ The manager also wrote that people can have a private phone-line fitted in their bedrooms or can make private phone calls on a mobile handset. A dedicated residents’ phoneline is due to be installed. Staff also assist people to keep in touch with family and friends by supporting them to write letters. The inspector shared a table with three people living in the home for the lunchtime meal. Attractive menus had been provided, offering two choices of main course and dessert, although one person said alternatives to the menu were also available. The meals were attractively presented and appetising. The chef regularly seeks feedback from the residents and records their views. This information is used to continually monitor and improve the catering service provided. The high standard of catering in evidence at the last inspection has been maintained and is commended as an example of best practice. Holmfield DS0000067934.V362012.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. Procedures are in place to listen to the views of people living in the home and staff are trained in safeguarding their welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager and staff adopt a positive attitude to complaints and see them as opportunities to continually monitor and improve the quality of the service provided. The complaints procedure is posted at three different locations in the home and is also provided in information packs issued to people admitted to the home. Six people completing surveys said that they had been informed about how to express concerns or complaints. Two people commented, “The management staff deal immediately with any concern I or my mother has” and “The staff are always available to speak to me, either on the phone or in person. Nothing is too much trouble for them. All the staff are first class.” Suitable procedures are in place to safeguard people living in the home from harm and staff have received training in this area. Staff on duty were able to demonstrate that they would take appropriate action if they suspected abuse. Since the last inspection safeguarding issues have been managed well and the correct procedures have been followed. Holmfield DS0000067934.V362012.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. Considerable improvements have been made to provide a more comfortable, safe and pleasant environment for people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection an application to reduce the number of bedrooms had been approved by the Commission. The office had been moved to a larger room near the front entrance door and the previous office had been converted into a treatment room for use by the district nursing team. This provided evidence of a commitment to maintaining the privacy and dignity of people using the service. Considerable capital had been invested since the last inspection to replace the central heating boiler, laundry equipment, carpets and redecoration to several Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 18 areas of the home. A partnership had been forged with a North East brewery to redecorate the lounge areas and the total refurbishment of the kitchen was imminent. This had resulted in significant improvements to the environment and the comfort of people living in the home. One person commented in a survey, “Lots of improvements are taking place now that Age Concern are there. Everywhere is clean, cheerful and bright and getting better all the time.” The maintenance and servicing of the home’s equipment was up to date. On a tour of the building the home was found to be clean and no offensive odours were detected. The laundry area was tidy, although it would benefit from redecoration and the removal of a build up of dust and fluff behind the laundry equipment. Staff should receive training in the control of infection to ensure that good practice guidelines are being followed and to protect the welfare of people living in the home. Holmfield DS0000067934.V362012.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. Care staff receive the right amount of training to competently meet the assessed needs of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sufficient staff are deployed to meet the assessed personal and healthcare needs of people living in the home. However, it was noted during the visit that care staff spend much of their time undertaking laundry duties and answering the front door during the busy morning period. Additionally, in surveys and from a conversation with the daughter of a service user it appeared that there have been a number of complaints concerning clothes going missing in the laundry. It is recommended that the provider consider employing laundry and administration/reception support in the mornings to enable staff to concentrate on their caring duties and to provide continuity of care for people receiving the service. Six personnel files examined provided evidence that staff had been carefully checked before being offered employment at the home. This ensures that only staff with the right personal qualities and experience are selected to work with older people. Some care vacancies still needed to be filled, to eliminate the need to use agency staff. Three people commented in completed surveys that Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 20 they valued the permanent staff, but were less complimentary about agency staff, who they thought did not show the same commitment. Personnel files also provided evidence that staff had received mandatory training in health and safety and three members of staff said that they had achieved a National Vocational Qualification at level 2 in care. A senior carer said that she was being sponsored by Age Concern to study for this qualification at level 3. This example of good practice ensures that staff have the knowledge and skills to understand and meet the assessed needs of older people. Holmfield DS0000067934.V362012.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 and 38 Quality in this outcome area is good. This home is managed in the best interests of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager for this service is suitably qualified and experienced. She has demonstrated a commitment to continual monitoring and review of outcomes experienced by people using the service and this has resulted in significant improvements to the way the service is provided. In the selfassessment document completed by the manager, she says, “All managers at Holmfield have a strong background in providing care services for older people and are committed to developing the service to the benefit of our service users. We have tried hard to develop and learn from any mistakes we make.” Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 22 Evidence of this was demonstrated in the way that the requirements and recommendations made at the last inspection have been complied with. The home’s quality assurance system has been further developed to include surveying the views of health and social care professionals. Feedback on the quality of the service from care management teams, general practitioners and district nurses has been complimentary. It is pleasing to note that their suggestions for improvement have been taken on board. Additionally, their views have been incorporated into Holmfield’s current annual quality audit report. Policies and procedures for the secure management of service users’ spending money are robust. A recent incident of a member of staff not following these procedures resulted in the loss of some money belonging to one person living in the home. This was thoroughly investigated by management and dealt with under the home’s disciplinary procedure. Age Concern has since repaid the amount lost to the service user. A sample of health and safety records was examined and found to be accurate and up to date. During a tour of the building to assess health and safety, a bedroom door was found to not fully close within its rebate. One of the people accommodated in this double bedroom was confined to bed and was at serious risk of harm from smoke inhalation in the event of a fire. An immediate requirement was left with the person in charge to resolve this issue within 24 hours. A telephone call to the home the following week confirmed that a contractor had corrected the problem the day after the inspection visit. Holmfield DS0000067934.V362012.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Holmfield DS0000067934.V362012.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. 1. Standard OP38 Regulation 23 (4) Requirement The registered person must ensure that fire doors shut fully into their rebates to prevent potential harm to service users from smoke inhalation in the event of a fire. Timescale for action 11/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered provider should consider providing training and development to staff to improve their recording skills. This will provide evidence that the assessed needs of people using this service are being met appropriately. Information sheets should be added to care plans to record important personal information relevant to the individuals living in the home. 2. OP7 Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 25 3. OP8 Records of service users’ weight should be recorded using either imperial or metric measurement. This will avoid confusion when assessing potential weight loss or weight gain. Prompt action should be taken at the monthly reviews of care plans to investigate the cause of significant weight loss or weight gain. This will afford protection to the health and welfare of people living in the home. The registered person should reinstate separate records to detail the outcome of service users’ health appointments. Detailed records should be held to provide evidence that district nurse instructions in relation to pressure relief and fluid intake are being adhered to. The assessment and care planning processes should incorporate the needs of people experiencing bereavement and loss in order to demonstrate that their emotional, psychological and mental health needs are being met. Personal and confidential information belonging to service users should be securely retained in the home in accordance with data protection legislation. The laundry should have its décor and cleanliness maintained to a satisfactory standard. Staff should be trained in infection control procedures in order to provide protection to the health and welfare of people living in the home. The provider should consider employing laundry and administration/reception support at busy times of the day. This will enable care staff to provide continuity of care for people living in the home. 4. OP8 5. 6. OP8 OP8 7. OP11 8. OP12 9. 10. OP26 OP26 11. OP27 Holmfield DS0000067934.V362012.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Holmfield DS0000067934.V362012.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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