Inspection on 23/10/06 for Holly Hall House

This inspection was carried out on 23rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Hall House 29/08/07

Holly Hall House 05/12/05

Holly Hall House 26/07/05

Holly Hall House 07/09/04

Holly Hall House 20/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Holly Hall House 170 Stourbridge Road Dudley West Midlands DY1 2ER Lead Inspector Mrs Cathy Moore Unannounced Inspection 23rd October 2006 07:30 Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 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 Hall House DS0000025034.V314416.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 Adults 18-65. 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 Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Hall House Address 170 Stourbridge Road Dudley West Midlands DY1 2ER 01384 252219 F/P01384 252219 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) Select Health Care Limited Teresa Owen Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 05/12/05 Brief Description of the Service: Holly Hall House is registered to provide care to 10 service users who have a diagnosed learning disability and fall within the younger adults age range (1865 years). A condition has been approved for the home to provide care to 1 named service user who has a learning disability who is over 65 years of age. Holly Hall House is situated on the main Stourbridge Road in Dudley, it can be easily accessed by public transport. The local public transport enables service users to visit other neighbouring areas and places of interest such as Merry Hill shopping centre and Dudley town. Holly Hall House is a large Victorian traditional domestic type dwelling. It comprises of ten single bedrooms (one with en-suite facilities), two bathrooms, one shower room, five toilets (including the ones available in the shower/ bathrooms) an office, kitchen, laundry, dining room and lounge. Car parking is available at the front of the property and garden areas to the side and rear of the home. The home provides service users with opportunities to develop skills for independence. All service users are encouraged to use suitable community facilities and resources and attend day care facilities or college. The charges for this home range from £361-£1100 per week. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.30 and 15.00 hours. The inspection process assessed the key National Minimum Standards for younger adults. To aid the inspection process a number of questionnaires were forwarded to the home for completion before the inspection. A proportion of the inspection was conducted in the living areas where care practices and staff/resident interaction could be observed. During the course of the inspection three residents’ files to include assessment of need and care plan documents were assessed. Three staff files to include recruitment documents and training were also assessed. The premises were part assessed to include the lounge, the dining room, the laundry, kitchen, bathroom and toilets. Medication systems and the safe keeping of resident money were assessed. The breakfast time was partly observed. Five residents and two staff were spoken to during the inspection. The deputy manager and a senior manager were on site during the inspection process. What the service does well: The atmosphere of the home is very warm and welcoming. There is a strong ‘homely’ feeling. The staff are friendly and polite and react well to the service users in their care. Staff/ service user interaction observed was very positive. The residents were not apprehensive in approaching the staff with questions and requests. There is a strong friendly bond between the residents. Friendly banter between them all was on-going. Residents looked well cared for and well presented. They all choose their own clothing and personal effects. The premises are well maintained, decorated, furnished to a good standard, a score rating of 4 which is excellent was given for the internal premises. Furniture, fixtures and fittings are all domestic in style. The home was seen to be clean and hygienic. Record keeping generally is of a good standard. There are good links between the home and community care professionals. Trips, outings and leisure time activities are carried out daily. All residents go on holiday at least once a year. A score rating of 4 which is excellent was given for the leisure and activity provision offered by the home. The home encourages service users to maintain contact with family and friends. Ten of the ten completed service user questionnaires received confirmed that they liked living at the home. Ten of ten also confirmed that they felt safe in the home. One service user said; I like living here. I like all the staff”. Another said; “ Good this home is. They care for us a lot. We have good holidays and Christmases”. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 6 Staff spoken to all commented how much they “ liked working at the home” and that they felt that “ All service users received the care that they need”. They said that the staff worked well as a team and that they felt supported. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 The overall outcome for this group of standards is judged to be good. No service users are admitted into the home without them having a full assessment of needs. Prospective service users can be assured that the home will endeavour to meet their needs and aspirations. EVIDENCE: It is extremely positive that 10 of the 10 service user completed questionnaires revealed that they all liked living at the home. This was further confirmed by service users spoken to. One said; “ I likes living here”. Another said; “ I like living here. Good this home is”. No new service users have been admitted to the home for some considerable time. However, history and evidence seen in the past has demonstrated that the home has in place a comprehensive assessment of need process which includes; a staff member from the home meeting and assessing the service user, information being obtained from the funding authority, trial visits and overnight assessment stays. The home has on a number of occasions been asked to confirm that the primary/ main needs of the residents accommodated are their learning disability and has given the assurance that this is correct. Generally, it was Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 9 identified that the home is meeting the needs of all but one of the service users including physical, recreational and other aspects. Unfortunately, one resident’s needs have deteriorated the senior and deputy manager confirmed that ‘ On-going communication had been maintained with the service users funding authority highlighting behavioural concerns and other issues’. A new home is being sought for this service user where needs can be managed. It was identified that one service user does not attend any external facilities and has no family. There has not been a formal re-assessment or review for this service user for some time by his funding authority. A requirement has been made for a request to be made to the funding authority for this to be addressed. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The overall outcome for this group of standards is judged to be good. A care plan was available for each resident whose file was examined. Ample evidence was available to demonstrate that service users wherever possible are enabled to make decisions about their lives. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: 10 of the 10 completed service user questionnaires received revealed that they all had a care plan. This was evidenced further by examination of three service users files during the inspection. It was extremely positive to see that service users had signed their care plan to confirm their awareness of the document and their involvement in its production. Generally, care plans were informative and contained a wide range of information relating to individual needs and preferences. There was evidence that care plans are being reviewed monthly. Last reviewed in October 06 however, it was suggested that this process be expanded to ensure that any changes are fully captured, for example, the service user who has had mobility Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 11 deterioration and the service user whose needs can no longer be met by the home. All residents spoken to confirmed that they are encouraged to make decisions about their lives. This includes all aspects examples being; whether they attend college, what they do on any given day, who they see. They choose and purchase their own clothing. They purchase bits and pieces for their bedrooms. Risk assessments were in place across a range of areas. One had been produced for service users who choose to go out independently shopping or to college. Another for a service user who regularly stays with her family for overnight stays. One service user who has a chronic chest disorder has been made fully aware of the risks of smoking by staff and health practitioners yet chooses to continue to smoke. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,16,17. The overall outcome for this group of standards is judged to be good. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in a wide range of appropriate leisure activities. Service users are encouraged to maintain contact with family and friends and are supported if they wish to have personal relationships. Service users are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: It is extremely positive that all 10 resident completed questionnaires confirmed that they have lots to do. Seven residents attend educational or day centre facilities. Three either choose not to attend or places to meet there needs are not available at the present time. One resident said; “ I go to college on Mondays and Wednesdays”. The Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 13 three residents that do not attend outside facilities were all taken out shopping to Brierley Hill during the inspection. Leisure and recreational opportunities offered to the residents is very good. The home has its own transport which enables regular trips and outings in the local community and further a field. Residents are very much encouraged to attend to their own affairs in the community such as going to the bank, shops etc rather than these things being done on their behalf. All residents have been away on holiday this year, some three times. One resident said, “ We have good holidays and Christmases”. Another said, “ I like going out on the outings”. Residents told the inspector how much they had enjoyed a trip to Blackpool the previous Saturday and about their forthcoming Halloween parties. A number said that they were going to go Christmas shopping within the next week or two. Ample evidence was available to demonstrate that residents where possible do have contact with family or friends and this is very much encouraged by the home. A couple of residents spend time with their family. One had been on an overnight stay with her family during the weekend. There was also evidence to show that residents phone their families in between visits to maintain verbal contact. There was evidence available to demonstrate that daily routines are determined by resident choice. During the morning it was observed that individual residents got up at a time suitable for them. Some residents do have to be out of the home at certain times for day centre and other appointments attendances and require some reminding/ prompting from staff. Completed resident questionnaires confirmed that residents can choose what they want to eat. All but one said that they go out with the staff food shopping this resident answered sometimes to this question. The home does have a written menu but to remind residents daily what meals are to be provided the meals for any given day are documented on a board in the dining room. The dining room is a good size. It is warm and welcoming and a focal place in the home where residents congregate. Breakfast time was partly observed- either residents were asked what they would like to eat or they prepared it themselves, cereals and toast. Tables were nicely laid with serviettes provided. A lot of conversation and friendly banter was exchanged between residents before, after and during their breakfast. Generally the residents either eat out or have a light lunch at lunchtime. They have their main meal together during the evening. Food stocks seen were plentiful and varied. Fresh fruit, vegetables and salad were available. One resident said; “ The food is good”. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. The overall outcome for this group of standards is judged to be adequate. Service users receive personal support in the way that they prefer and require. Some improvement is needed to ensure that the service users health needs are met. Some improvement is needed to ensure that medication processes and management is completely safe. EVIDENCE: Generally all residents can attend to their own personal care needs but with varying amounts of help, guidance and supervision. Residents are very much where possible encouraged to maintain their independence in this area. One resident said; “ Look after myself, hair everything”. One resident who had been supervised showering said; “ I enjoyed that- I feel lovely”. There was ample written evidence to confirm that residents have access to a range of healthcare professionals examples being; the optician, Community Psychiatric Nurse, consultant for learning disability and the doctor. This further confirmed by completed resident questionnaires in which all said that they saw a doctor and dentist. Evidence was available to demonstrate that residents are weighed regularly however, a concern was raised about weight gain of one resident which could Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 15 be detrimental to her health and lack of referral to an appropriate professional for advise about this. Another concern raised was the fact that although risk assessments are being carried out they are not being carried out frequently enough or when changes occur. For example one resident’s mobility has changed dramatically over the last 6 months yet her risk assessment had not been revised. The home has a medication policy however, this is rather fragmented which may make it difficult to access specific information quickly if needed. The medication policy must be reviewed and up dated to ensure that it contains all aspects of medication safe handling. It is positive that no staff initials gaps were identified on medication records and that the home has a medication trolley to enhance safety. The home has a good system in place for the handing over of medication keys between shifts. A number of shortfalls were identified and include the following. The trolley was left with the keys in its lock unsupervised. The home does not have a safe, lockable box for storing medications that require refrigeration for example; one residents insulin pens. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The overall outcome for this group of standards is judged to be good. A complaints procedure is in place for the service users to access if they are unhappy. Processes are in place to protect service users but they need to be reviewed. EVIDENCE: It is positive that completed resident questionnaires all confirmed that residents know who to speak to if they are unhappy. The home has a complaints procedure which is available in a pictorial and written formats. No complaints have been received by the home or the Commission. It is extremely positive that completed resident questionnaires all confirmed that they feel safe at the home. Reference to the NCSC (where the telephone number is quoted) detailed on the complaints procedure must be changed to CSCI as this is the name of the regulatory body as has been since 2004. No allegations or incidents of abuse have been reported. The home has in place procedures to prevent abuse and processes in case an allegation or incident of abuse were to occur however, these needs to be reviewed to ensure that it is up to date and contains all valid information. . All staff but the new ones have received abuse awareness training. It was refreshing and rare to see that certificates to evidence the training actually stated what the training consisted of and that the training made reference to the Local Authorities protection processes. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 The overall outcome for this group of standards is judged to be good. Service users live in a homely, comfortable and safe environment. Shared spaces complement service user’s individual rooms. The home is clean and hygienic. EVIDENCE: The owners ensure that the home when needed is redecorated and refurbished. Since the last inspection laminate flooring has been fitted in all corridors, which look really nice. One resident said; “ Do you like the new floor?”. The home is well maintained, décor furnishings and floorings of a good standard. The home is bright, cheerful, comfortable, domestic in style with a warm, friendly atmosphere. The home has a good sized lounge and dining room described in an earlier section of this report which are well furnished and decorated to a good standard. The home was found to be clean and orderly with no offensive odours. The laundry again, is domestic in style. Residents washing laundered individually to prevent feelings of institutionalisation and any possible Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 18 contamination. Action however, needs to be taken to ensure that the laundry sink is cleaned at least daily as it was not adequately clean. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The overall outcome for this group of standards is judged to be adequate. The home must continue with its efforts to ensure that 50 of the staff have NVQ level 2 or above in care. Recruitment process require some‘ Fine tuning’ and development to ensure the safety of the service users’. Service users are supported and supervised by staff. EVIDENCE: Although it is very positive that a number of staff are working towards their NVQ and the home has almost attained the required ratio of 50 of the staff team having this award they have not yet reached this target and must continue with their efforts. Four staff files were viewed, they were seen to be fairly well organised and held securely to ensure confidentiality. It was pleasing to see that each file contained two written references, an application form and health declaration. Shortfalls however, were identified that need to be addressed examples being; the manager does not have sight of the original Criminal Record Bureau (CRB) checks for staff. The only record the home has of these checks is the number and date of the document. Further, evidence suggested that these CRB documents are destroyed within days of them being received by the organisations head office. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 20 For one staff member there were no dates of employment preventing an audit of their employment history. Established staff employed have received a range of training. The deputy was able to confirm that new staff have been secured places on induction training. Generally 3 staff are provided during waking hours and one wakeful and one sleep in staff member at night. The deputy confirmed that these staffing levels are sufficient and that if additional staff are needed on any shift then this would be arranged. Staff spoken to had a good understanding of their roles and the likes and dislikes of individual residents’. Staff were positive about their jobs one said; “ The residents are definitely looked after here. Its good we all work as a team”. Another said; “ All staff get on well. The residents are looked after”. Residents made positive comments about the staff one said; “ I like the staff, I love ..”. Another said; “ I like all the staff and all the residents’”. Evidence was available to determine that staff receive formal one to one supervisions. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The overall outcome for this group of standards is judged to be adequate. A decision must be made about the return to the home of the manager from her secondment. Some self- monitoring and review processes to ensure that the home is run in the best interests of the service users are in place. Generally, health and safety within the home is observed. EVIDENCE: The manager has been on secondment to another home for sometime. The time has come when the registered persons must make a decision about her future and whether or not she will be returning. In the interim the deputy has been managing the home. It was noted from rotas that at time during some weekend shifts there are no seniors or managers on duty. This is inadequate and must be addressed to ensure the health, safety and well being of the residents’. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 22 It is positive that the home does undertake some monitoring and self audits of its performance and compliance with the National Minimum Standards. It is also positive that a senior manager visits the home regularly and produces a report of her findings on a monthly basis. Evidence was available to demonstrate that resident questionnaires are used within the home and that a number have been completed and returned from other stakeholders. There was no evidence however, to confirm that the results of the questionnaire analysis have been published. Generally, the home was seen to be adequately safe. Assessments and other methods are in place to ensure this. A random audit of service and other maintenance records was undertaken and were found to be in order. Records viewed included; the checking of fire fighting equipment, gas landlords certificate and the portable electrical appliance tests. The kitchen was briefly assessed. It was found to be clean and orderly. Flooring and kitchen units were seen to be of a good standard. Due to the ethos of the home ‘ The encouragement of independence’ the residents access the kitchen alone at times to make drinks. Regular risk assessments must be carried out to prevent harm of burning and infection outbreak concerning hygiene. Holly Hall House DS0000025034.V314416.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 Adults 18-65 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 x 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 3 x x 2 x Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 YA3 Regulation 14 Requirement The registered person and manager must ask the appropriate Social Services department to review (K). The registered person and manager must forward evidence to the CSCI to demonstrate that the competency of staff has been assessed in respect of monitoring blood sugar levels. This to include new staff. Timescale of 15/01/06 not fully met. One established night staff member has not received this training. Timescale for action 23/11/06 2 YA19 12(1)(a) 18(1)(a) 01/12/06 3 YA19 12(1)(a) 13(4) The registered person and manager must ensure that all risk assessments ( moving and handling/falls etc) are reviewed every 12 months or earlier if changes occur. 01/12/06 Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 25 4 YA19 12(1)(a) 13(4) 5 YA20 13(2) The registered person and manager must ensure that (KC) is referred to her doctor/ dietician or other concerning her weight gain. The registered person and manager must ensure that the homes medication policy/ procedures are fully revised. Timescale of 20/01/06 not met. This to include; Ordering and receipt of medications. Medication errors. 7 day retention of medication after death. The policy must be as one document, indexed and easy for staff to retrieve information. 08/11/06 01/12/06 6 YA20 13(2) The registered person and manager must ensure that a risk assessment is carried out for the service user who self medicates their nebuliser. 08/11/06 Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 26 7 YA20 13(2) The registered person and manager must; Purchase a suitable, lockable box for the storing on medications in the domestic fridge. Ensure that the medication trolley can be secured to the wall when not in use. Ensure that all staff are made aware not to leave the medication keys in the medication trolley unattended. 08/11/06 8 YA22 22(4) 22(7) The registered person and manager must ensure that the complaints procedure is amended to include : The CSCI.( Not NCSC)where the telephone number is detailed. 20/11/06 9 YA23 13(6) The registered person and manager must ensure that all adult protection procedures are reviewed/ revised. This to include the missing persons procedure dated 2002. Timescale of 01/02/06 not met. 01/12/06 Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 27 10 YA23 13(6) 11 YA30 13(3) The registered person must ensure that the flow chart included in Dudley Councils protection procedures ‘ Safeguard and protect’ is fully completed with names and contact numbers and is readily available for staff to reference. The registered person and manager must ensure that; The laundry sink is cleaned at least every day. Proper provision is made in the laundry for the ventilation from the tumble dryer ( should go outside). The registered person must ensure that staff continue with their N.V.Q training to ensure that the prescribed 50 attainment rate is achieved as soon as possible or by March 2007. Timescale of 01/03/06 nearly met. 01/12/06 08/11/06 12 YA32 18(1)(a) 01/03/07 13 YA34 13(6)19(2) The registered person and manager must ensure that; A satisfactory CRB/ POVA list check is received for all staff before they commence employment. It is only in ‘exceptional circumstances’ where a staff member can commence on a Pova first in which case the CSCI must be informed. Where the decision is made for a staff member to commence on a POVA first 06/11/06 Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 28 (and the CSCI have been informed) then a risk assessment must always be Carried out and a named supervisor be nominated . 14 YA34 17(2) 19(2) The registered manager must obtain the formal codes of conduct and practice issued by CRB on the storage and disposal of CRBs. Timescale of 12/01/06 not met. 15 YA34 17(2) 19(2) The registered provider and manager must ensure that ; The manager has site of all prospective staff members CRB/POVA list checks or at least a full memo is provided as evidence of a clear CRB/POVA list check. CRB’s are retained for at least 6 months before destroying. 16 YA34 17(2) 19(2) The registered provider and manager must ensure that past employment dates are provided by prospective employees ( on their application forms) to enable an audit/ identify any employment gaps. The registered person must inform the CSCI whether or not the manager intends to return to her post at Holly Hall House if not a suitable candidate for the job must be recruited. 06/11/06 06/11/06 23/11/06 17 YA37 8 01/12/06 Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 29 18 YA37 18(1)(a) 19 YA39 24 The registered person and manager must ensure that a senior is on shift each weekend during waking hours. The registered person and manager must ensure that recent outcomes of resident satisfaction surveys are published. Timescale of 01/02/06 not met. 01/11/06 01/12/06 20 YA42 13(3) 13(4)(c ) The registered person and manager must; Undertake regular risk assessments to minimise/ eradicate the likelihood of scalding and infection transmission due to service users accessing the kitchen. Ensure that all opened food packets are stored in air tight containers. 06/11/06 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 YA37 Good Practice Recommendations The registered manager should continue with work to achieve the registered managers award. Holly Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 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 Hall House DS0000025034.V314416.R01.S.doc Version 5.2 Page 31 - 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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