Inspection on 18/10/07 for Holly Tree Cottage

This inspection was carried out on 18th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Tree Cottage 20/02/07

Holly Tree Cottage 08/11/05

Holly Tree Cottage 26/05/05

Holly Tree Cottage 12/10/04

Holly Tree Cottage 04/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Holly Tree Cottage 243 Berrow Road Berrow Burnham-on-Sea Somerset TA8 2JQ Lead Inspector Judith McGregor-Harper Unannounced Inspection 18th October 2007 09:45 Holly Tree Cottage DS0000058862.V352727.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 Tree Cottage DS0000058862.V352727.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 Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Cottage Address 243 Berrow Road Berrow Burnham-on-Sea Somerset TA8 2JQ 01278 788008 01278 787939 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) www.homes-caring-for-autism.co.uk Somerset Homes Caring for Autism Ltd Mrs Tania Michelle Palmer Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Upstairs bedrooms must only be used for service users who are physically mobile. 20th February 2007 Date of last inspection Brief Description of the Service: Holly Tree Cottage is registered with the Commission for Social Care Inspection to provide care and support for up to seven people who have a learning disability. The house is a large detached property set close to public transport links and within walking distance of a shop and public house. All bedrooms are for single occupancy and three bedrooms have full en-suite facilities. The home has two communal bathrooms located on the first and second floors. Communal areas are located on the ground floor; these consist of a dining room, a lounge and conservatory area. There is a domestic style laundry facility. To the rear of the property is a large garden. The home is owned by Somerset Homes Caring for Autism Ltd. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was conducted by one inspector. The inspection lasted one day. We (the Commission) met a high proportion of the care and management team and spoke with one person who lives at the home. We also received survey responses from six people living at the home, six relatives and five staff. On the whole the comments were extremely positive in relation to the care and support provided at Holly Tree Cottage. People were happy with the services that they receive. There is much evidence that service users are fully involved in decision making and access many community facilities. There are no vacancies at the home. Seven young adult men live at the service. As part of the inspection process we viewed records in relation to care and support plans, health and safety, medicines, risk management, the management of behaviours and physical intervention and staff recruitment. We also viewed communal, and on invitation, private areas of the home. As a result of this inspection the home has two recommendations for good practice regarding care planning and decoration of the home’s environment. There is a requirement made in relation to health and safety. What the service does well: What has improved since the last inspection? Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 6 At the last key inspection in February 2007 three requirements and ten recommendations were made. The home has met all the requirements and had fully implemented seven of the recommendations. The service has developed more concise risk assessments for individual service users that are easily accessible for both staff and person using the service. Managers have supervised the staff facilitating the Service User Meetings to ensure that they act as facilitators and do not impose their views, wishes or opinons onto people using the service. Care plans have been reviewed and details of each individual service users Reward System has been placed their individual care and support plans. The changes to the plans have been recorded and relayed to the staff team to ensure that everyone has adapted their work practices for each individual. The frequency of staff supervisions and staff meetings has increased. The home has conducted service user questionnaires and relative questionnaires as part of the home’s quality assurance. 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. The summary of this inspection report can be made available in other formats on request. Holly Tree Cottage DS0000058862.V352727.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 Tree Cottage DS0000058862.V352727.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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 1. Standard 2 is not applicable as there have been no admissions since the last key inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Homes Caring for Autism have a clear and descriptive Statement of Purpose and an individual brochure to Holly Tree Cottage that outlines the ethos of the organisation, the location and facilities to the home, local amenities and the layout of the rooms within the home. The brochure contains pictures for reference. This helps people considering entering the service make an informed choice about the home. EVIDENCE: The Statement of Purpose and Service User Guide reflect the services offered in the home. The Statement of Purpose was updated in February 2007. The fees charged vary according to the individual’s assessed need. Currently fees range from £1650 to £2250 per week. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holly Tree Cottage is able to demonstrate that it always strives to promote equality of opportunity through assisting meaningful choices in daily activities for people living at the service. Individual diversity of needs are also sensitively supported through a risk assessment framework. EVIDENCE: We inspected four care and support plans. It was noted that the care and support plans had recently been reviewed/updated and were detailed providing evidence of a person centred approach. Since the last inspection the service has worked to review the care planning system to provide information to staff about individual’s current needs in a summarised form. It was not always clear from examining care plans which aspects of care individuals living at the home had been consulted on, however, and the service ought to give further consideration to how they will be able to demonstrate this. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 10 The care team complete a daily diary for each person at the home recording the activities and care and support provided on a day-to-day basis. This is kept in the form of a monthly document. The care team also complete monthly summaries. The home uses a ‘reward system’ as part of the process used to address the management of behaviours. Where a ‘reward system’ is in place to manage behaviours the person has a specific reward that they have chosen which will be delivered if certain goals are achieved. The explanation and the use of each individual’s reward are detailed with targets set and are detailed in an individual’s care and support plan. Six survey responses were received from people living at Holly Tree House. To the question ‘Can you do what you want during the day, night and weekends?’ all six responses stated ‘Yes’. To the question ‘Do you make decisions about what you do each day?’ four people answered ‘Always’ and two people answered ‘Sometimes’; no replies stated ‘Hardly Ever’ or ‘Never’. Presently, none of the people living at the home are fully able to manage their finances. The relatives of six people act as appointees. The service has set up a system for one service user to independently ‘part manage’ their finances. Records are kept of all transactions. The home has completed a number of individual risk assessments to address the management of behaviours, safety and promoting independent living skills (and restrictions of). These were inspected for the people whose care plans were inspected. The risk assessments viewed had all been recently reviewed and dated. Where a person holds a faith this has been respected and staff support has been provided to enable regular worship in the community. In the AQAA submitted by the home it is stated that Service User meetings are held on a regular basis and that the management is considering how to best facilitate private feedback forums for individuals who prefer not to attend group meetings. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 11, 12, 13, 14, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holly Tree Cottage offers many suitable opportunities to access community based facilities that reflect personal likes and aspirations of people using the service. Contact with families is encouraged and promoted. The home involves people in the development of menus and strives to promote healthy lifestyles through a balanced diet and regular exercise. EVIDENCE: In the AQAA submitted to the Commission by the home it states, “Holly Tree Cottage has been able to identify and offer access to further education and work experience courses that individual servcie users have expressed an interest in. Holly Tree Cottage is able to provide support and transport to these courses if required by the needs of the individual. Holly Tree Cottage provides individual Service Users with the opportunity of accessing activities Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 12 and clubs that they enjoy and find stimulating. These include main stream clubs and activities (swimming pools, gym, cinema, horse riding, )as well as learning disability specific clubs ( Such as the sports centre, KIT club, Gym). Holly Tree Cottage uses local (public) community facilities and amenities and makes full use of public transport for the Service Users. This enhances their community presence as well as giving them opportunities to develop more skills and develop relationships with other members of the community. All Service Users have up to date contact details for family in their care records. All family contact is recorded in the Service Users records under family and professional contact, describing the date, time, method, content of conversation, action required, by whom and timescale to do it within. The Service Users were supported to create a healthy balanced menu to cover all of their favourite choices. Fresh fruit and fruit juices are always available. Some Service Users are on a healthy eating programme to help with their weight issues. This involves exercise coupled with healthy eating options. Low fat alternatives are always offered.” Five survey response from relatives answered questions about the running of Holly Tree Cottage in the following way. To the question ‘Does the home keep in touch with you?’ four responses stated ‘Always’, one ‘Sometimes’. To the question ‘Does the home support people to live life they choose?’ three stated ‘Always’, two ‘Usually’ and 1 ‘Sometimes’. One response stated that they believed activities “agreed upon had been dropped”. Another person wrote that “the places they go on day trips seem exceptional, appropriate to service users and individual needs and interests.” There is a printed weekly activity planner for each person in the home. One person showed the inspector their activity planner before going out to attend an appointment. During the inspection other people were out of the home on planned activities/work placements and one person was receiving intensive staff support. There is a portable phone at the home that people can use to contact families and friends if they do not have a personal mobile phone. All post is delivered to service users unopened and staff offer assistance with correspondence if requested. All people living at the home are offered the use of a key to their bedroom, even if they then choose to not lock their bedroom door. The home has a computer with Internet access for use by people living there. There are firewall systems in place and policy guidelines for staff detailing excluded sites to protect people living at the service and prevent criminal activity. People living at Holly Tree Cottage cook meals with the staff team. There is a four-week menu that gives a wide variety of meals. There is a clean, modern kitchen with appropriate records of food, fridge/freezer temperatures maintained. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holly Tree cottage manages personal support of the young men living at the service in a professional, sensitive and inclusive manner. EVIDENCE: People living at the home are registered with a GP and access services from other healthcare professionals as and when needed. Records inspected provided good audit trails of appropriate referrals to community health care support such as to speech and language therapists, physiotherapy and mental health services. We inspected medication management systems in the home. Medication Administration Record sheets (MAR) were correctly signed when administered or refused. Some medication is given on a PRN (as required) basis and the home has guidelines for the use of such medicines. Medication is securely stored either in individual’s rooms in a dedicated locked storage cupboard or in a locked cabinet in the manager’s office. Currently no one living at the home Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 14 administers their own medication. The ability for people to administer their own medications is assessed in their care plans. Recently employed staff spoken with who had not yet received medicines administering training confirmed that they were not administering medicines and understood that it would be a breech of the company policy to do so. Since the last inspection the service has written a homely medicines policy and has consulted with individual’s GPs regarding suitable homely stock to retain at the home. On the day of the unannounced inspection the staff were engaged with managing some challenging behaviour. This was handled thoughtfully, professionally and sensitively with clear communication between staff, people living at the service and community mental health specialists. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and management have good awareness of measures to take to safeguard vulnerable people living at the home. Clear policies and procedures are in place to direct staff. Complaints are investigated robustly, which provides confidence to people who may wish to express their concerns. EVIDENCE: The home has policies and procedures in respect of making a complaint, recognising and reporting abuse and whistle blowing. The Complaints procedure is located in the homes statement of purpose and service user guide. The AQAA completed by the home stated that the home has received five formal complaints. When viewing the Complaints record it was noted that these complaints had been investigated thoroughly and there was evidence of good consultation with the person raising the complaint throughout the investigation processes. Staff spoken to were aware of the whistleblowing policy and demonstrated the action that they would take. Survey responses from people living at the home indicated a good level of confidence they had in feeling able to raise concerns within the staff/management team. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 16 Staff spoken with during the inspection stated they had received training in the protection of vulnerable adults this year and that this training included scenario discussions. This is good practice. The home management has informed the Commission of challenging events in the home where there has been a risk of or actual harm sustained by staff or persons living at the home. The home uses a reward system in relation to the management of behaviours. Staff spoken with at the inspection had been trained in the use of positive response training (PRT). Records are kept of all incidents and where physical intervention has been used this has been recorded. The Manager countersigns incident records as part of the audit process in order to monitor the number of incidents that may necessitate the use of PRT. Holly Tree Cottage DS0000058862.V352727.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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 24, 25, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holly Tree Cottage provides a comfortable home for people. Some areas would benefit from redecoration to enhance the appearance of communal areas. EVIDENCE: We viewed most areas of the home. The premises are accessible to all the people living there. There is a communal lounge with a conservatory off of this area and a large dining room. In September 2007 major refurbishment of pipe work took place over one week, which necessitated vacancy of the premises. Staff and young men living at Holly Tree Cottage went on a short break to the North Devon coast during this time. Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 18 CCTV is installed at the home but this is restricted to entrance areas for security purposes. One person showed the inspector their bedroom. The room was pleasant, roomy and reflected their personal taste. Three bedrooms have full en-suite facilities. There are two communal bathrooms on each floor. There are adequate toilet facilities. The home has appropriate hand washing and hand drying facilities. The home has a domestic style laundry. All cleaning chemicals are stored securely. The laundry room appeared suitably managed. On the day of the inspection the home was clean and free from offensive odours. In two survey responses from relatives concern was aired that at times the domestic cleanliness of the home was not of a high standard expected. These comments were passed to the management for their consideration. Communal areas and corridors would benefit from redecoration, as the décor is looking tired. There have been breakages and damages to fixtures and fittings recently and these were being repaired by the maintenance team when we arrived unannounced at the service. Bathrooms are somewhat austere in decoration. The manager stated the reason for this was because of the level of challenging behaviour currently at the home. Holly Tree Cottage DS0000058862.V352727.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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by a motivated and well supported staff team in suitable numbers who have attended appropriate training to enable them to meet their individual needs. EVIDENCE: The home employs seventeen care staff. A total of six care staff have obtained NVQ Level 2 qualification or above and a further four are working towards this. Eleven staff have left the service in the last year. We inspected the records of staff reasons for leaving the service. Reason for leaving did not support a hypothesis that staff were unhappy working at the home. During the inspection we spoke privately and individually with duty staff who all reported feeling happy and supported working at the service. Five staff surveys were received. Responses indicated that staff had received an adequate induction, that there was always a senior member of staff on duty Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 20 and that staff had undertaken training in the protection of vulnerable adults and receive regular supervision. Training records indicted that the majority of staff have undertaken training in autism awareness, epilepsy, communication and picture exchange communication system (PECS). All staff have received positive response training (PRT). Some staff have received training in Somerset Total Communication (STC). Staff spoke positively regarding the training opportunities provided by the organisation and quality of training events. Staff complete feedback forms rating the quality of internal training events for manager’s quality audit processes. Presently there are usually five to six care staff on duty during the day, although due to the need to provide additional support to the service on the day of the unannounced visit, these numbers were exceeded. There is a one waking and one sleep in person during the night. Rotas are adjusted to meet the specific needs of service users, which is commendable. The service acknowledged in their AQAA that on occasions activities/events are cancelled due to staffing shortages. This is usually due to staff sickness and annual leave. Staff will usually provide cover at short notice to avoid service user’s disappointment if activities are cancelled, but this is not always possible. The AQAA advised that the provider is in the process of creating a ‘Flex team’ of staff that will be available to all homes, so that appropriate staffing levels may be maintained at all times. Recruitment files of five recently appointed staff were inspected. The files contained all the required documentation as required by Schedule 2 of the Care Homes Regulations 2001. All staff undertake induction training. There were good records maintained for staff induction processes and the induction programme was thorough and service specific. The induction includes mandatory training and specialist training. Holly Tree Cottage DS0000058862.V352727.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. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected Standards 37, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is effective management at the home that strives to include the views of those people using the service and staff working at the home in order to improve service provision. Safety at the home is taken seriously in order to prevent accidents. EVIDENCE: The registered manager is Tania Palmer. She has recently become the home’s manager. Previously to this she was the home’s deputy manager, then acting manager. She holds the NVQ 4 Registered Manager’s Award and has experience of managing a care home prior to working for Home’s Caring For Autism. A survey response from one relative of a person living at the home Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 22 described the manager as “very approachable, and communication is very good.” As part of the home’s quality assurances annual stakeholder surveys are sent out. This usually occurs in November. The organisation’s Director of People and Culture has recently changed the quality assurance questionnaires and is developing a process to collate the information gained, analyse the results and feedback to interested parties. There had been a recent extensive upgrade of plumbing pipework in the home. On a tour of the environment and in testing hot water outlets this seems to have affected some of the mixer valves installed, making outlet temperatures hot and a potential risk of scalding vulnerable people living at the service. The manager had already ordered thermometers to keep records for hot water outlets. The recording of safe temperatures and adjustment of mixer valves must be addressed. The home detailed records of routine required servicing of equipment in the home via the AQAA process. Incident and accident records were inspected. These were maintained in detail and countersigned by the manager, including action plans to address triggers for incidents or measures to reduce hazards that may cause accidents. Chemical products used in the home that may pose a risk to health were stored safely and securely. Holly Tree Cottage DS0000058862.V352727.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 3 2 N/A 3 X 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 3 ENVIRONMENT Standard No Score 24 25 26 27 28 29 30 3 3 X 3 X 2 3 X 3 X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000058862.V352727.R01.S.doc 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Tree Cottage Score 3 3 3 X 3 X 3 X 3 2 X Version 5.2 Page 24 No 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 YA42 Regulation 13 (4) (a) Requirement The home must keep records of regular checks of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 43 degrees Celsius for baths and 41 degrees Celsius for showers. Timescale for action 08/12/07 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 YA6 Good Practice Recommendations Wherever possible service users should be involved in the development of their care plan and sign their agreement. The service should give consideration to how ownership and authorship of care plans is achieved and demonstrated. Communal areas in the home would benefit from redecoration to enhance the environment where decoration is looking tired. 3. YA24 Holly Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Tree Cottage DS0000058862.V352727.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!