Inspection on 26/07/05 for Holly Hall House

This inspection was carried out on 26th July 2005.

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 23 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 23/10/06

Holly Hall House 05/12/05

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 170 Stourbridge Road Dudley West Midlands DY1 2ER Lead Inspector Cathy Moore Unannounced 26th July 2005 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 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 Stationary 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 E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holly Hall House Address 170 Stourbridge Road, Dudley, West Midlands, DY1 2ER Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01384 252219 01384 252219 Select Health Care Limited Ms.T.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 E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 service user over the age of 65 years. 1 L.D(E) Date of last inspection 7th September 2004 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 Rd 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. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by one inspector during 08.15 to 12.30 hours. The inspection was carried out as the first of the homes two statutory inspections for this inspection year. The premises were partly assessed which included three bedrooms, one bathroom, two toilets, the lounge, dining room, laundry and ground floor corridor. The garden areas were also viewed. Two residents, both new to the home, were selected for case tracking purposes. This processes included the assessment of their personal files, the viewing of one bedroom and speaking in detail to one. One other resident’s bedroom was also assessed. Three staff files, maintenance records, training records and complaints information were also perused. What the service does well: Residents, appear to be happy and content. Overall the standard of record keeping is good. Evidence is maintained using tick charts to demonstrate care and other areas delivered. The home is maintained and has a warm, welcoming, positive atmosphere. Positive comments were received from residents’. One commented, “ I like my room”. “ Another said, “I like the staff”. Others commented positively about their regular trips, outings and holidays. Activity provision is of a high standard one resident said, ” I am always out. We go out every day”. There was ample written and photographic evidence available to demonstrate trips, outings, holidays and services accessed in the community. A number of residents attend educational facilities on a regular basis. One resident expressed satisfaction with her educational facility. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Care plans require expansion and the assurance that all needs will be incorporated into these, examples being diabetes care and areas of risk. Staffing levels must be reviewed and increased particularly during weekends. The grass area in the rear garden requires attention as it is of a poor standard. Rubble has accumulated which could present as a risk to residents. In its present state it is unusable. Staffing levels are inadequate and require review. Staff numbers must be increased particularly during weekends. Greater diligence is needed in respect of staff recruitment and health and safety processes. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 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. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 2,3,4,5 Users’ individual aspirations and needs are assessed. More diligence is required to ensure that prospective service users’ know that the home will meet their needs and aspirations. Prospective service users’ have the opportunity to visit the home before they are admitted to assess its suitability. More diligence is required to ensure that each service user has a terms and conditions document that it fully completed. EVIDENCE: Case tracking of the two new residents’ demonstrated that an assessment of need had been carried out prior to them being offered a placement. Assessment documents from funding authorities and other appropriate agencies had been obtained and were also included on the residents’ files. The primary need of each resident was not highlighted on the assessment documentation. A number of residents accommodated have a range of secondary needs. One new resident has a number of medical conditions, one of which requires regular blood testing. The home was not familiar with the medical conditions as they should be. Needs can not be met unless staff are fully conversant with conditions that they have to monitor. There was no written acknowledgement to (P) and (S) of how the home will meet their needs. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 10 All prospective residents have an opportunity to visit the home and spend time at the home before they are admitted. This confirmed by speaking to one resident and perusing records and policies. A 12 week trial period is then initiated for new residents. The trial period to give all parties the opportunity to determine the suitability of the placement before it is made permanent. A terms and conditions document was included on the file of both new residents’. This document was seen to be well presented and informative. However, the terms and conditions had not been fully completed for either of the new residents’. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 6,7,8. Care plan processes require further development to ensure that all needs are incorporated within. Evidence and records confirm that service users’ are encouraged and enabled to make decisions about their lives. Evidence and records confirm that service users’ are consulted with, and participate, in all aspects of life in the home. EVIDENCE: Care plans were seen in place for each resident. The format of the care seen and their content were acceptable. However, not all assessed needs, diagnosis or risks were included. One resident has diabetes which is managed by the administration of insulin. There was no care plan to instruct the staff of complications of the diabetes such as hyper or hypoglycaemia, the signs and symptoms of such, or what to do if these symptoms are identified. There were no care plans in place for needs such as taking medication on an ‘as needed’ basis, special diets, limitations, nutritional or tissue viability risks. Care plan instruction was limited, in some areas there were no specific instructions on what should be done, how, when, by who or how often. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 12 There was ample evidence available to demonstrate that residents, are encouraged to make decisions about their lives, examples being what they want to do on any given day or weeks ahead. Residents’ are involved in decision making in respect of the homes décor, purchasing of new furniture, outings, holidays, meals and menus. Similarly residents’ are very much involved in the running of the home and daily routines. Staff were heard asking residents’ if they would like to go out. One resident commented that she wanted to go clothes shopping and told staff the items that she would like to purchase. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12,13,14, 15. Residents’ who want to have opportunities for personal development. All residents participate regularly, if not daily in age and peer appropriate activities. All residents’ access and utilise facilities in the local community Leisure activities offered at the home must be commended. EVIDENCE: All residents’ who want to attend day centres or educational facilities. One resident commented, “ I really like my centre”. Evidence was available to demonstrate that staff at the present time are making arrangements for a new resident to attend a day facility. All residents’ on a daily basis access the local community. A number are able independently to access the community independently. Residents’ visit shops, go out for meals on a regular basis. Activity provision is of a very high standard, one resident commented” we go out everyday”. It was clear that residents’ enjoy shopping. They also enjoy car boot sales. On the 20 July everyone went out for a meal and on 21 July they Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 14 went to the Safari Park. Residents’ went on holiday to Devon in April, Great Yarmouth in June. Other holidays are being planned for September or October 2005. The home encourages all residents’ to maintain contact with family and friends. One resident was staying overnight at her aunts’ house, another visits her father every week. One spends time at her brother’s or mother’s house. Visiting times are open and flexible. However, in general residents’ visit their relatives rather than relatives visiting the home. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 18,19 Residents’ receive personal support in the way they prefer. Generally, residents’ physical and emotional needs are met. EVIDENCE: All residents’ are able to attend to their own personal care needs. A number require only prompting or supervision. One resident commented, “ I always wash and dress myself”. She was insistent that she was observed on how well she could independently brush her teeth. All bedrooms are of single occupancy. A choice of a bath or shower is available. There was ample evidence to suggest that main health care services are accessed on an as needed or regular basis. The district nurse visits on a daily basis to administer one residents’ insulin. Staff have been trained in diabetes awareness and how to monitor blood sugars, however, there was no evidence of training certificates or deemed competency in respect of this. The dental care provider is being reviewed at the present time. Optician input has been secured. The manager commented, “ I am aware that a specially trained optician is needed for people who have diabetes”. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 16 There was ample evidence of weight monitoring, tissue viability and nutritional assessments. Identified risks from these assessments are not always being reflected in the care plans. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 22 The present complaints procedure content is not accurate or complete in some areas. EVIDENCE: The home has a complaints procedure in operation. The complaints procedure detailed the NCSC not CSCI. There was no 28 deadline detailed in the procedure. No complaints have been received by the home or the CSCI for 12 months. The home has a complaints monitoring system in place where the complaints log is assessed on a monthly basis. The home also has available copies of ‘ Complaints for People’ information which is in a pictorial format. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 18 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 standard(s) 24,25,26,28,30 Overall residents’ live in a homely, safe environment. Bedrooms suit the residents’ needs and lifestyles and promote independence. Bathrooms and toilets provide sufficient privacy. Communal areas in the home complement and supplement residents’ individual rooms. Hygiene procedures require more diligence. EVIDENCE: The home was seen to be well decorated and maintained. It was warm, welcoming and has a homely feel. External redecoration of rendering will need to be refreshed in the near future. The garden is small but in general is of a good standard with the exception of the rear grass. The grass looks bald and has bricks and rubble accumulated which could present as a risk. Due to the poor standard of the grass this area is not often used. Three bedrooms were viewed. These were seen to be of a good quality in respect of décor, carpets and furnishings. All bedrooms seen contained a number of residents’ personal belongings examples being pictures, ornaments, music systems and televisions. One resident commented “Like my bedroom”. When asked if she had everything in her bedroom that she required her response was, “yes”. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 19 One resident has her own kettle and drink making facilities in her bedroom. An audit in respect of items provided in each room has been undertaken, however some required items were not mentioned. The home provides a dining room and one good sized lounge. These rooms are of a good standard. Flooring in both is of a laminate type. Four new two seater and two one seater leather chairs have been purchased for the lounge. This room looks very impressive. Overall the cleanliness of the home appeared satisfactory, although the landing by (K’s) bedroom was in need of a good vacuum which may have been attended to later in the day. There were no odours identified. Signs to remind residents’ to wash their hands after using toilet facilities were not available. The laundry is domestic in size and style. It is located in an area that does not require any thoroughfare. The home has a domestic style washing machine which is capable of reaching temperatures of 95oc and one dryer. At the present time no resident is incontinent and none has any infectious condition. Residents’ laundry is all washed separately. Procedures to prevent contamination of dirty and soiled washing were not available. The sinks in the laundry were not sufficiently clean, the substance on these sinks appeared to be paint. Material towels and some personal items were seen in the bathrooms and toilets. The ground floor bathroom had a number of towels stored on shelving. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 Inadequate staffing levels are being provided at the home particularly at weekends. Staff recruitment processes require further development to prevent risks to residents’. EVIDENCE: The home is now operating to full capacity in respect of resident numbers. Staffing levels are inadequate particularly during weekends. A file was in place for each staff employed. A number of shortfalls were identified in that three staff had commenced employment before their enhanced disclosure/POVA list check had been received. There was only one source of identity for one staff member, no reference had been received form the direct past employer for one staff member. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 Residents’ benefit from a well run home. Overall health and safety issues are observed. However, greater diligence must be paid to ensure that servicing of equipment is carried out to the required frequency. EVIDENCE: The manager has within the last month been assessed by the Commission for Social Care Inspection as a ‘ fit person’ to run and manage the home. The manager is working towards the registered managers award. Overall health and safety is being observed. The internal checks of fire fighting equipment are being carried out to the required frequency. There was evidence available to demonstrate that monthly audits in respect of health and safety are being carried out as per the homes quality assurance monitoring processes. A gas landlord’s safety service is required and the five year fixed electrical wiring test is due this year. Fire alarm and emergency lighting service certificates were not available. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 22 A number of gaps were identified in respect of staff mandatory training. Exposed copper pipes were seen in the ground floor bathroom. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 2 x 2 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 x 2 Standard No 11 12 13 14 15 16 17 x 3 3 4 3 x x Standard No 31 32 33 34 35 36 Score x x 2 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Hall Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 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 YA2 Regulation 12(1)(a) (b) 14(1) Requirement The registered person and manager must ensure that the main primary need is highlighted on each residents file. Consultaion with the residents consultant or other reliable source must take place to confirm each residents primary need. The registered person and manager must ensure that a written acknowledgement is given to the prospective resident or their represenative to confirm all assessed needs and how these will be met. The registered person and manager must ensure that they and all staff are fully conversant with any medical diagnosis pertaining to prospective residents in order for them to be able to confirm needs arising from these diagnoses can be met. ( This particularly so in the case of (S) ). The registered person and manager must ensure that the terms and conditions documents in respect of (S) and (P) are fully Timescale for action 26.07.05 2. YA3 14(1)(d) 26.07.05 3. YA3 12(1)(a) (b) 26.07.05 4. YA5 5(1)(b) (c ) 05.08.05 Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 25 completed. 5. YA6 15(1) The registered person and manager must ensure that all needs, wants, desires, goals and risks are reflected and incorporated within the residents care plans. ( To include care plans in respect of special diets, diabetes, limitation, risk, medical conditions, medication-( PRN as needed medication regimes )etc. The registered person and manager must ensure that all care plans detail the need/ problem/ risk what must be done in order to meet the need, how, when, by whom and how often. The registered person and manager must forward evidence to the CSCI to demonstate that the competency of staff has been assessed in respect of monitoring blood sugar levels. The registered person and manager must ensure that the complaints procedure is amended to include : The CSCI.( Not NCSC) A 28 day deadline for responding to complaints. 9. YA24 13(4)( c) 23(2)(o) 23(2)(e) The registered person and 01.09.05 manager must ensure that the back grass area is developed into a usable, safe place. 01.09.05 The registered person and manager must ensure that the audit format contains all items listed instandard 26 . All items on the list must be offered where they are refused or it has been assessed that they may present as a risk then this must be Version 1.40 Page 26 15.08.05 6. YA6 15(1) 15.08.05 7. YA19 12(1)(a) 18(1)(a) 15.08.05 8. YA22 22(4) 22(7) 20.08.05 10. YA26 Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc recorded. 11. YA30 13(3) The registered person and manager must ensure that: The sinks in the laundry are cleaned at least daily. That procedures are produced to prevent contamination between clean and dirty washing and that these are displayed in the laundry. That appropriate hand wash signs are provided in all toilets and bathrooms. The registered person and manager must ensure that: Towels and personal items are not stored in communal toilets or bathrooms. Material towels are not used as a matter of course in communal toilets or bathrooms. If a resident wishes to use this type of towel then it must be used for single purpose only and returned to their bedroom or be put for laundering after use. The registered person and manager must carryout a review of staffing levels. Staffing levels must be incresed accordingly. A staffing proposal must be forwarded to the CSCI. 14. YA33 18(1)(a) The registered person and manager must ensure that three staff are provided during all waking hours on weekends. The registered person and manager must ensure that a 30.07.05 20.08.05 12. YA30 13(3) 08.08.05 13. YA33 18(1)(a) 10.08.05 15. Holly Hall YA34 13(6) 19(2) 26.07.05 Page 27 E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 16. YA34 17(2) 19(2) 17. YA34 13(6) 19(2) 18. YA34 19(2) satisfactory CRB/ POVA list check is receieved for all staff before they are allowed to commence employment ( CRBs are no longer portable). The registered manager must 20.08.05 obtain the formal codes of conduct and practice issued by CRB on the storage and disposal of CRBs. The registered person and 26.07.05 manager must ensure that at least one of the two required references is obtained from the prospective staff members direct previous employer. The registered person and 26.07.05 manager must ensure that at least two forms of identity are obtained from each staff member and that these are retained on their staff file. Timescale of 07.09.04 not fully met. The registered person and manager must ensure that a full employment history is obtained from all prospective staff members. Timescale of 07.09.04 not fully met. The registered person and manager must ensure that the title on staff job descriptions matches the job title detailed on their CRB/POVA list check. The registered person and manager must ensure that the required work is carried out in order for the following service certifiactes to be issued: Gas landlords safety certificate. Emergency lighting. 19. YA34 13(6) 19(2) 26.07.05 20. YA34 19(2) 10.08.05 21. YA42 23(2)(c ) 15.08.05 Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 28 Fire alarm system. Copies of these certificates must be forwarded to the CSCI. 22. YA42 13(4)(a) The registered person and manager must ensure that all exposed copper pipe work in bathrooms ( or other areas) is suitably guarded. The registered person and manager must ensure that training is arranged for all staff who have not to date receieved the required mandatory training. 15.08.05 23. YA42 13(1)(c ) 18(1)(a) 26.08.05 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 acheive the registered managers award. Holly Hall E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen 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 E55 S25034 Holly Hall V240200 260705 Stage 4.doc Version 1.40 Page 30 - 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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