Inspection on 21/11/07 for Holly Bank Care Home

This inspection was carried out on 21st November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holly Bank Care Home 24/07/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holly Bank Care Home 70 Manchester Road Heywood Rochdale Lancashire OL10 2AW Lead Inspector Val Bell Unannounced Inspection 10:00 21st and 23 November 2007 rd 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 Holly Bank Care Home DS0000066359.V355121.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. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Bank Care Home Address 70 Manchester Road Heywood Rochdale Lancashire OL10 2AW 01706 623388 F/P 01706 623388 hollybankmanager@eaglecarehomes.orangehome.co.uk None Eagle Care Homes Ltd 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) ** Post Vacant *** Care Home 38 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (38) of places Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 38 service users to include: *Up to 38 service users in the category of OP ( Old age , not falling with in any other category) *Up to 22 service users in the category of DE (E) (Dementia - over 65 years of age). Service users with dementia must be accommodated on the ground floor only. Date of last inspection 9th August 2007 Brief Description of the Service: Holly Bank is a large detached house standing in its own grounds. It has been extended to provide accommodation for 38 older people, providing personal care for all. Thirty-eight single rooms are provided, 34 of which are en suite. The home is situated in a residential area on the outskirts of Heywood and is on a main bus route. A local shop and Post Office are situated nearby and there is a public bowling green to the side of the home. Ramped access is provided to the rear and both sides of the home. The area outside the conservatory has been landscaped to provide a large patio with a water feature. Car parking is available to the front and side of the home. The most recent Commission for Social Care Inspection (CSCI) report was available in the entrance area. At the time of this inspection weekly fees were between £348 and £375 per week. Additional charges were for hairdressing, aromatherapy, chiropody, toiletries, newspapers, dry cleaning and laundering of delicate fabrics. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the home’s random inspection on 5th April 2007 and supporting information in the form of a self-assessment provided by the manager prior to a visit to the home. Site visits to the home form part of the overall inspection process and the lead inspector conducted two visits on 21st November and 23rd November 2007. The opportunity was taken to look at the core standards of the National Minimum Standards (NMS). This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visits time was spent in conversation with people living in the home and discussions were held with care staff, senior care staff, the acting manager/area manager and provider, a social worker and five relatives visiting at the time. A sixth relative was contacted by telephone. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: A recent change in management arrangements at the home has resulted in significant improvements to the service provided. This was confirmed in conversations with people throughout the two inspection visits. One relative whose family had complained about the service some months ago said that there had been a definite improvement. She said that the manager listens to concerns and takes action to put things right. It was evident that the service is being managed in the best interests of people living there. People referred to the home receive a thorough assessment of their needs and the manager spends time with them and their family to ensure that they have enough information to decide if the home is the right place for them to live. Similarly, care plans are developed by talking to people about how they would like their needs to be met. Daily activities are provided, although people can choose to spend time on their own if they wish. The meals provide people with a choice of preferred diets and special diets are catered for. The home’s environment is clean and regularly maintained and systems are in place to monitor health and safety and keep people safe from harm. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: No requirements were made during this inspection. Seven good practice recommendations were made. The manager said that it was sometimes difficult to obtain care manager assessments of need before people were admitted to the home. Incidences of this should be recorded in the person’s care plan. Three recommendations related to care plans and risk assessment procedures that would give staff additional information in providing care in a safe way. Minor adjustments should be made to the system of accounting for money held on behalf of people living in the home. This should provide an audit trail for tracking any discrepancies that might occur. A waste bin in one of the bathrooms was not fitted with a suitable cover. This should be replaced with a covered bin to minimise the risk of infection. Care should be taken to obtain full employment histories for all staff selected to work in the home. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 7 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. Holly Bank Care Home DS0000066359.V355121.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 Holly Bank Care Home DS0000066359.V355121.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. People admitted to the home participate in their assessments of need to make sure that their care and support is provided in a way that suits their preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People being admitted to the home are provided with a Service User Guide that informs them of their rights and the care and support they can expect. This document is written in large print and is in a style that is both warm and welcoming. Another document called the Statement of Purpose is available to people using this service. It provides information on the aims and objectives of the care home and a statement as to the facilities and services that the registered person will provide. Both documents were being reviewed and updated to meet the requirement made at the last inspection. This will ensure that people making enquiries about this home are provided with accurate and up to date information on which to decide if the home will be the right place for Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 10 them to live. The relatives of a person recently admitted to the home were visiting during the inspection. They said that they had been to look at five homes before they made a decision to choose Holly Bank for their mum. They chose this home because it seemed more homely and more suited to her needs. They had been given a copy of the service user guide and a member of the family had signed a contract provided by the home. Six care files were examined for evidence that individuals’ needs had been assessed prior to admission to the home. Comprehensive, in-house assessments had been undertaken prior to all six people being admitted to the home. Two relatives visiting during the inspection confirmed that the family had been invited to participate in their mother’s assessment and the document had been signed accordingly. It was pleasing to note that the assessment recorded how the person would prefer her care to be provided. The quality of care manager assessments, however, was variable. One of these provided by a care manager related to a previous assessment for care in the community. This assessment information was not appropriate for a person being cared for and accommodated in a home. In another instance the care manager had not provided an assessment document. The acting manager explained that it was sometimes difficult to obtain the necessary paperwork from care managers and that this had been raised during a recent meeting attended by the managing director of Eagle Homes and Social Services. This information is important for ensuring that staff are aware of the full range of a person’s care and support needs. Instances where care manager assessments of need have been requested but not provided should be documented in the person’s notes. The home did not provide an intermediate care service. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Robust systems for care planning and administration of medication ensure that people living in the home have their personal and healthcare needs met safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six care plans were examined for evidence that individual’s assessed needs were being met. The acting manager, Mandy was in the process of reviewing all care plans to bring them up to date. Four of the care plans had been reviewed and contained very detailed information that informed care staff what they needed to do to meet individual’s assessed needs. Risks to the safe delivery of care had been thoroughly assessed and clear instructions had been written down to inform staff of the action needed to keep people safe. Two minor shortfalls were found. One person had been diagnosed as suffering from hallucinations and regular urinary tract infections and staff were regularly monitoring this. It was recommended that guidelines for monitoring the hallucinations be obtained from the health professional. This will provide staff Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 12 with relevant information to identify changes in the person’s mental health that may be triggered by an underlying infection. The second shortfall related to a care plan for providing personal care, such as washing, bathing and toileting. The person had fragile skin and was at risk of skin tears. This had been suitably assessed, although a reference to the risk assessment had not been recorded in the care plan. By including a reference in the care plan staff will be reminded of the extra care needed when assisting this person with their personal hygiene. During the inspection, one of the six people was visited by her social worker to review her care at the request of her daughter. She was concerned that her mother had experienced a number of falls resulting in an injury, two months previously that required treatment in hospital. It was found that this person’s needs had not been assessed prior to her discharge from hospital, as required under the home’s policy and procedures. Consequently, the risk of further falls had not been managed appropriately. The social worker said that she was confident that the current management had now made sufficient improvements to minimise further risk to her client. A high volume of falls, involving sixteen people had been recorded in the seven months prior to this inspection. It was recommended that the manager obtain advice from the health service’s falls prevention nurse to determine if the strategies in place can be improved. Significant improvements had been made since the last inspection by involving people and their relatives in developing care plans. Signatures had been obtained from the people involved in the care planning process and relatives spoken to, confirmed their involvement. It was particularly pleasing that the care records contained a list of signatures of staff and health and social care professionals to evidence that they had read and understood care plans. This is an example of good practice. Relatives spoken to praised the care and support provided. One relative commented as follows, “I am pleased with the care and attention to mum’s physical needs.” Care plans also contained evidence that people living in the home had access to the full range of community healthcare services. Observation of the lunchtime medication administration on the dementia unit provided evidence that individual medication was being signed for at the point of administration. Medication records for the six people being case-tracked were accurate and up to date. A sample of their medication in stock was assessed as accurate according to the balances held in the records. Where medication had not been administered an explanation had been written on the back of the medication record sheets. The daughter of a recently admitted resident said that there were some initial problems in obtaining her mother’s medication. She added, “I was very impressed with how the staff sorted out the problems with my mum’s medication. This was done in a very professional Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 13 manner.” A senior care assistant had been delegated responsibility for the management of medication received into the home. She showed the inspector the systems in place for the receipt, storage, auditing and return of medication to the pharmacy. These systems demonstrated that people living in the home received their prescribed medication safely. Holly Bank Care Home DS0000066359.V355121.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 good. People are provided with healthy diets according to their individual preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records detailed the activities that people took part in and the outcome of their involvement. The activities co-ordinator explained that two one-hour group activity sessions were provided daily. This was in addition to individual activities such as manicures and occasional trips. On the first days visit, bread making was provided in the dining area and a bingo session was held on the second day. One relative said she was pleased that staff were motivating her mother to socialise with other people and join in activities because she tended to isolate herself in her room. The manager said that her key worker was keen to obtain some Braille books and the relative responded that her mother used to read Braille but had lost interest. She said it would be good if the key worker could motivate her mum to start reading again. This will provide evidence of a developing person-centred service. This was discussed with the manager who was keen to develop further opportunities for people to follow their preferred lifestyles and personal interests. This could be achieved by Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 15 developing the staff’s knowledge of individuals’ life histories to identify the specific interests that people find interesting and stimulating. The manager said that relatives would be invited to become involved in this. Five relatives were asked if staff made them welcome when they visited. The relatives said that they were always welcomed and made to feel involved. The relatives also confirmed that staff kept them informed of any concerns they had if a person’s needs changed The balances of personal money held on behalf of four residents were checked. Two of these balances were accurate, receipts had been obtained and records had been audited regularly. The remaining two records detailed small inaccuracies in the balances of money held, although the owner had replaced the amount of the shortfalls during auditing of the accounts. It is recommended that inaccurate balances should be investigated to identify how the shortfalls arose. Kitchen and food storage and preparation areas were clean and tidy and all food was labelled and stored correctly. The chef said that food safety records were up to date. These were not examined, as there had been an environmental health inspection the previous month. Minor shortfalls had been found although these had been addressed by the inspector’s second visit during November. The midday meal and breakfast were observed on the dementia unit during this inspection. Both mealtimes were calm and relaxed and people were assisted as required. Breakfast provided a choice of cereals, grapefruit, toast and hot food according to individual choice. The midday meal provided people with a choice of two main meals in addition to soup and dessert. The chef said that alternatives to the menu were always available, as were snacks and drinks on demand. Menus provided evidence that healthy diets were offered to people and it was pleasing to note that the chef blended and presented soft diets as separate items. One of the relatives said, “Mum is on pureed food. The different foods are pureed and arranged separately. This looks much more appealing.” This provided evidence of good practice in meeting special dietary needs. Holly Bank Care Home DS0000066359.V355121.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. People using this service are listened to and afforded protection from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the period from May to October 2007 five people contacted the Commission to express concerns about standards in the home. Three of these complained about the cleanliness in the home and the numbers of staff on duty. The manager was asked to investigate two of these complaints with the third referred to the local authority for investigation. One of the complainants said that she did not feel that the issues had been resolved satisfactorily. Another relative commented that the previous manager promised to put things right but no improvements were ever made. This was discussed with the current manager who gave an assurance that she would meet with the family concerned to discuss the unresolved issues. Other relatives said that there had been a definite improvement generally since the current manager had been running the home. One said, “Mandy listens to our concerns and takes action to put things right.” Procedures for protecting people from harm had been implemented in the home and a copy of the local authority’s policy on safeguarding adults was available for staff guidance. Staff on duty demonstrated a good understanding of the policy and procedures for keeping people safe and the action they must Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 17 take if abuse was suspected or alleged. This affords protection to the welfare and safety of people living in the home. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. People admitted to the home are provided with a maintained and comfortable living environment that meets their physical needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was undertaken to assess the quality of the environment and health and safety within the home. The environment was found to be clean and hygienic and suitable adaptations had been made to assist people with impaired mobility. It was evident that there had been ongoing replacement, redecoration, refurbishment and maintenance of equipment to provide a safe, homely and comfortable environment for people living in the home. Bedrooms were personalised and suitably furnished as confirmed by three relatives that were satisfied with the facilities provided. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 19 Bedroom door locks had been changed as required at the last inspection and a master key provided for staff to enter rooms in an emergency. Health and safety procedures ensured that hot water temperatures were regulated to minimise the risk of scalding and fire exits and escape routes were free from obstructions. Communal space included a conservatory, which provided a pleasant outlook over landscaped gardens. Bathrooms included equipment for assisted bathing and shower facilities. The laundry was clean and tidy and individual baskets were provided for returning clothes to a person’s room. Procedures to control infection were in place and staff were observed to use appropriate personal protective equipment such as disposable gloves and aprons. A waste bin in one of the bathrooms did not have a lid fitted, which could potentially create a risk to the control of infection. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Robust recruitment and staff development opportunities ensure that staff have the right qualities, knowledge, skills and integrity to safely meet the needs of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the previous four weeks staff rotas revealed that a manger, team leader, five care assistants and ancillary staff had been on duty each day and three staff on during the night. Team leaders on each shift are qualified in first aid at work. This level of staffing was sufficient to meet the assessed needs of the thirty-two people living in the home. Mandy, the acting manager said that improvements had been made to the way that staff were deployed. Significantly, staff were required to take their breaks individually on each floor so that sufficient staff were available to assist people where necessary. Fifteen staff had achieved a National Vocational Qualification at level 2 or above and seven staff were currently working towards this qualification at level 2. In conversation with staff on duty it was evident that they had a good understanding of the needs of older people and specifically how to meet the assessed needs of the people they cared for. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 21 Five personnel files were examined for evidence of suitable recruitment procedures and relevant training. One application form did not list the dates of the person’s previous employment. A full employment history should be obtained and explanations obtained for any gaps in employment. Criminal Record Bureau checks and two written references had been obtained for the staff prior to employment. Similarly, proof of address and identity had also been confirmed. Undertaking these checks ensures that the staff employed to work at the home have the integrity and personal qualities necessary to work with older people. Examination of the home’s training matrix and records for 2007 provided evidence that staff have accessed training courses in safe moving and handling, fire safety, safe food handling, safeguarding adults from harm, managing aggression, dementia and infection control. Additionally, training was planned in medication administration and assessing the capacity to make decisions as defined under the Mental Capacity Act. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The home is being managed in a responsive way in the best interests of people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Significant improvements had been made to how the home was being run following recent changes in management. This had resulted in a much more responsive service. Mandy, the company’s area manager was temporarily in charge pending the recruitment of a suitable replacement for the previous manager who had resigned. Mandy had worked hard to identify and resolve outstanding issues by undertaking systems audits and consultations with people living in the home and their representatives. One relative, whose family had previous expressed concerns said, “Things have definitely improved Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 23 since Mandy took over. There is some way still to go but a definite improvement.” Other relatives commented on how they are encouraged to participate in the admission, care planning and review processes. As part of the home’s quality assurance and monitoring programme, satisfaction surveys are issued to relatives every six months. The most recent survey included the following comments, ‘solve problems as quickly as possible,’ ‘concerns addressed immediately,’ ‘activities have improved,’ ‘staff are aware of mum’s needs and respond patiently. She is not just a number’ and ‘the rear gardens are attractive.’ Additionally, Mandy has introduced regular residents’ meetings the most one being held on 12th November 2007. the minutes of this meeting covered issues discussed such as catering, current management arrangements, activities and forthcoming special celebrations. Furthermore, Mandy provided evidence of the monthly audits that managers are required to undertake and she was currently bringing these up to date. This provided evidence that people and their representatives are listened to and action is taken to make improvements in their best interests. Staff do not take responsibility for becoming appointees for benefit purposes. A sample of health and safety records was examined and found to be accurate and up to date. In particular the requirements made at the previous inspection relating to health and safety and first aid training had been met. Holly Bank Care Home DS0000066359.V355121.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 3 X 3 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 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 3 Holly Bank Care Home DS0000066359.V355121.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. 1. Refer to Standard OP3 Good Practice Recommendations Instances where care manager assessments of need have been requested but not provided should be documented in the person’s notes. Advice should be sought from a health professional on monitoring hallucinations and urinary tract infections experienced by the person mentioned in this report. Care plans should include references to risk assessments to remind staff of the care needed in keeping people safe. Advice should be obtained from the falls prevention nurse to establish if the strategies for keeping people safe from injury are effective. Records of the personal expenditure and income of people living in the home should contain an audit trail that DS0000066359.V355121.R01.S.doc Version 5.2 Page 26 2. OP8 3. 4. OP8 OP8 5. OP14 Holly Bank Care Home identifies any errors and/or inaccuracies. 6. 7. OP26 OP29 Waste bins should be fitted with suitable covers to prevent the spread of infection. Full employment histories and explanations for any gaps in employment should be obtained from candidates for employment. This will determine if the applicant is suitable to work with older people. Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 27 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 Holly Bank Care Home DS0000066359.V355121.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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