CARE HOME ADULTS 18-65
Holly Tree Cottage 243 Berrow Road Berrow Burnham-on-Sea TA8 2JQ Lead Inspector
Jane Poole Announced 26 May, 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 Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Holly Tree Cottage Address 243 Berrow Road, Berrow, Burnham-on-Sea, Somerset, TA8 2JQ 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) 01278 788008 Somerset HCA Ltd Mr Paul Thomas Personal care home only 7 Category(ies) of Learning disability (7) registration, with number of places Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Upstairs bedrooms must only be used for service users who are physically mobile. Date of last inspection 12 October, 2004 Brief Description of the Service: Holly Tree Cottage is registered with the Commission for Social Care Inspection to provide care for up to 7 people who have a learning difficulty. The house itself 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 all have en suite facilities. Communal areas are located on the ground floor, these consist of a dining room, a lounge and conservatory area. The home is owned by Somerset HCA Ltd, the responsible individual is Shirley Smith and the registered manager is Paul Thomas. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over a seven hour period. During this time the inspector was able to meet 4 of the 5 service users, speak with staff on duty, tour the building, observe care practices and discuss issues with the management. 3 service users completed comment cards prior to the inspection and some comments have been incorporated into this report. 1 general practitioner completed a comment card and again comments have been incorporated into the report. The home provides a service to people who have autistic spectrum disorder and some service users were unable to fully express their views on the home. The inspector noted that everyone living at the home appeared comfortable in their surroundings and interacted well with staff. What the service does well:
The inspector was impressed by the enthusiasm and commitment of the staff team. The comment card received from a local GP also praised the staff. There are currently 5 service users living at the home and a further person is planning to move in, in the next few months. The pre admission procedure in respect of this person has been excellent. The prospective service user and their family have been able visit the home and the manager and key members of staff have visited the service user in their current home and worked alongside them at their school. An assessment of need has been received from the care manager and the home are in the process of completing their own assessment. Further visits are planned to the service user and they have been given information about the home including photographs of staff members. There is a wide range of activities in the home and one person attends college full time. It is planned that other service users will use local college facilities in the future. Service users are consulted about the day to day running of the home and take part in household tasks. Service users decide their own activity programme and as a group they prepare a menu for the coming week. Menus seen showed that service users are receiving a varied and balanced diet. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
The care plans seen by the inspector were poor and did not reflect the level of individualised care that service users are receiving. Documentation in respect of needs is unclear to the reader and would therefore be difficult for new staff or service users to understand. Although care plans are formally reviewed on a regular basis there was no evidence that amendments were made between
Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 7 reviews; for example when medication changes or when a service users’ wishes change. Some service users have a reward system and again the documentation in respect of this was unclear. The recruitment procedures in the home need to be reviewed to ensure that they provide maximum protection for service users. Currently staff begin work before Protection of Vulnerable Adults or Criminal Records Bureau checks have been applied for. Service users access a wide variety of activities and access the community on a daily basis. Currently staff working at the home wear a uniform of a bright blue sweatshirt and fleece top. This makes service users conspicuous when out with more than one member of staff and makes it difficult for them to integrate into the community. Staff spoken to were aware of the ability to take serious concerns out side the home but the whistle blowing policy is not on display. 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 Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 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 Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 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) 1, 2, 3 & 4. Thorough pre admission assessments are carried out with all prospective service users to ensure that the home is able to meet their needs. Service users are given adequate information about the home and are able to visit on more than one occasion before making a decision to move in. EVIDENCE: The home have recently up dated their statement of purpose and service user guide to reflect the changes that have occurred in the home since the last inspection. These documents were seen by the inspector, they are well written and set out what the home provides. All prospective service users are seen and assessed by relevant professionals and the home. At the time of this inspection the manager and key members of staff were working with a prospective service user who currently lives some distance from Burnham on Sea. The staff had visited the person in their home and had worked alongside them in the school that they are attending. The prospective service user had been able to visit the home with family members and had been given photos and other information about the home and the staff. It was apparent that a great deal of work was being undertaken in order to make the transition to the home a smooth one. The inspector saw the initial assessment and plans for future visits before the person left school and moved into Holly Tree Cottage on a permanent basis.
Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 10 The manager explained that they carried out thorough assessments to ensure the home would be able to meet the needs of any prospective service users. It was clear during the discussion that the home is aware that they may not be able to meet the needs of all service users referred to them. The home provides a service to people who have an autistic spectrum disorder and this forms a large part of the initial assessment. All staff are receiving ongoing training on autism and it’s implications for the service they provide. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 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, 9 & 10. Care plans are poor and not reflective of the individual care being provided to service users. Service users are consulted on the day to day running of the home. EVIDENCE: The inspector viewed the care plans of two service users. There are comprehensive assessments of need. Care plans seen had been created by care managers and home staff. The care plans seen did not appear to be a user-friendly document and were not easy for the inspector to follow, they would therefore not be easy for new staff or service users to understand. There was evidence of regular reviews but information had not been amended between reviews. Some service users take part in a reward system and again the documentation in respect of this was misleading. Each file also contained risk assessments that were personal to the individual. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 12 There is evidence that service users are consulted on all aspects of their care. There are regular service user meetings where people are able to raise issues and discuss ideas about the home. A member of staff and service users draw up menus on a weekly basis. Each service user plans their activity programme with staff on a weekly basis. The inspector saw that each service user had a copy of their weekly activity chart. All service users who completed comment cards prior to the inspection answered NO to the question “Do you wish to be more involved in the decision making in the home?” There is a board in the entrance hall that gives service users information on a daily basis. Pictures and symbols are used to make it easily understandable to service users. Staff spoken to were aware of issues of confidentiality and personal information was appropriately stored. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 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) 11, 12, 13, 14, 15 & 17. All service users receive a balanced diet and are able to make choices about the food they eat. Service users are assisted to take part in a wide range of leisure activities in line with their assessed abilities and interests. EVIDENCE: Service users are encouraged to learn independent living skills. Staff stated that service users are assisted to take responsibility for their own rooms and other household chores. The home has a vehicle, which can be used by service users to access the community but are also encouraged to use public transport. One service user attends college 5 days a week and two other service users are looking into college courses. The home places a high importance on activities and as previously stated service users draw up a weekly activity chart with staff. Service users access various community activities including local
Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 14 clubs and facilities. On the day of the inspection everybody had the opportunity to go out in line with their agreed plans. Some people went shopping and another went bowling using the bus. Service users access a wide range of leisure activities including swimming, cycling, visiting local towns, train rides, walking and meals out. All service users have recently taken part in sponsored activities to raise money for an assistance dog for a local resident. Currently staff working at the home wear a uniform of a bright blue sweatshirt and fleece top. This makes service users conspicuous when out with more than one member of staff and makes it difficult for them to integrate into the community. Visitors are welcome at the home at all reasonable times and many of the service users visit family members on a regular basis. The main meal of the day is in the evening when all service users are at home. The menus are written each week with service users. People are able to make suggestions about the meals that they would like and some service users assist with food preparation. Service users stated that they often have meals out as part of their activity programme. Menus seen show that there is a wide variety of meals providing a balanced diet. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 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 & 20. Service users have access to appropriate healthcare professionals. Any routines in the home are in line with the wishes and needs of service users. EVIDENCE: Routines in the home are flexible to enable people to choose what time they get up and when they go to bed. Staff are made available at appropriate times to ensure that people are assisted to be ready for organised activities: for example one member of staff starts work early each weekday morning to assist the person who goes to college. All service users have their own en suite facilities and there are two communal bathrooms where personal care is assisted with in private. There are male and female care staff, which enables people to have a choice of the gender of the carer who assists them with intimate personal care. All service users are registered with a local GP and other appropriate healthcare professionals such as dentists, opticians, psychiatrists and psychologists. A comment card was received from a GP prior to the inspection. They stated that they were very happy with the overall care provided, that
Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 16 they were able to see their patients in private and that the home communicated clearly with them. The comment card also praised the staff working at the home. All medical appointments are recorded. Each person living at the home has a medication cupboard in their bedroom and Medication Administration Records are kept for each person. The inspector viewed these records and found them to be correctly signed when administered or refused. Currently no service users self administer medication. Staff have received training in the care of some one who has epilepsy and the use of rectal diazepam. Records are kept of all seizures in the home. All staff who administer medication stated that they had received appropriate training. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 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 & 23. Service users are able to approach staff or management if they are unhappy about their care. The recruitment procedure should be improved to better protect service users. EVIDENCE: The home’s complaints procedure is available in the service user guide. No complaints have been received since the last inspection. Prior to the inspection the inspector received three comment cards that service users had been assisted to complete. All answered YES to the question “ If you were unhappy with your care, do you know who to speak to?” All stated that staff treated them well. Staff receive training on recognising and reporting abuse and a copy of the Somerset County Council’s ‘ Safeguarding Vulnerable Adults’ policy is displayed in the home. Staff spoken to were aware of the ability to take serious complaints outside the home but the whistle blowing policy was not clearly displayed. The home uses some physical restraint with service users. There is a physical restraint file and any restraint used and the reason for it is clearly documented and signed by the manager. The use of physical restraint has reduced since the last inspection. The home uses the Residential Care Providers Association to carry out Criminal Records Bureau checks on all staff. The current recruitment procedure is for staff to work shadow shifts in the home before a Protection Of Vulnerable
Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 18 Adults Check and enhanced Criminal Records Bureau check are applied for. Although it is acknowledged that staff do not work without supervision during this time the home must review this practice to ensure that staff do not work in the home before appropriate checks have been carried out. The home is not a financial appointee for any service user but they do hold small amounts of personal money for each service user. The procedures in respect of this are extremely robust. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 19 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, 27, 28 & 30. Holly Tree Cottage provides a comfortable safe environment for service users. Service users are able to make choices about the décor of the home and their personal rooms EVIDENCE: Holly Tree Cottage is located in a residential area of Burnham on Sea. It is close to local facilities including a pub and shop and is within walking distance of the town centre. It has access to public transport links. A fire detection system is fitted throughout the house. Service user accommodation is set over two floors. Communal areas consist of a large dining room, a lounge and a conservatory, all are located on the ground floor. Outside there is a pleasant secure garden. There is also a kitchen, which can be used by service users with staff supervision. The top/second floor is used as office space. This floor can only be accessed through the main body of the house and the home should ensure that visitors
Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 20 to this floor are kept to a minimum to protect the privacy of service users living at the home. All rooms are for single occupancy and all have en suite facilities, some have a toilet and wash-basin and others also have shower cubicles. There is a communal bathroom on each floor. The inspector viewed a sample of bedrooms and noted that they had been personalised to reflect the tastes of the individuals. There are appropriate laundry facilities and staff stated that service users are encouraged to participate in their own personal washing. Staff stated that there are plans to move the laundry to a space outside the home. They should ensure that service users continue to have access to these facilities. On the day of the inspection all areas seen by the inspector were clean and fresh. The home has only been open since February 2004 and the service users are beginning to choose colour schemes to make the house more homely and personal to them. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 21 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) 31, 32, 33, 34, 35 & 36. There is now a clear training programme for all staff to enable them to better understand the needs of service users. The recruitment practice in the home needs to be reviewed to minimise risks to service users. EVIDENCE: The inspector was able to speak with a number of staff during the inspection. All appeared well motivated and clear about their roles and responsibilities. There is a clear staff structure with each shift having a shift leader who allocates work and ensures the smooth running of the shift. In addition to the shift leaders there is a care manager and a junior care manager who work across all shifts and give direction and support to staff. Staff stated that there is always a senior member of staff on call. All service users are funded according to their level of need and the staff support which they require. Staff spoken to stated that there is always adequate staff on duty. Rotas given to the inspector showed that there is usually 5 staff on duty in the morning and 4 in the afternoon. The managers’ hours are in addition to this. Overnight there is one waking night carer and one
Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 22 person sleeping in. There are currently only 5 service users living at the home and these staffing levels are reflective of this. There is now a comprehensive training programme for all staff. New staff stated that they received appropriate induction training and initially worked alongside more experienced staff. All staff undertake the local authorities induction and consolidation courses. These cover a wide range of subjects such as first aid, food hygiene, infection control, protection from abuse, risk, epilepsy and providing support with personal care. In addition to this the new manager of the home has introduced comprehensive training related to the service users and their specific needs. This training focuses around autism awareness, challenging behaviour, person centred planning and Somerset Total Communication. Staff spoken to were extremely positive about the training opportunities within the home and felt that their understanding of the service user group was improving with the additional input from the management team. It is clear that the manager places great importance on staff training and has certainly made great improvements in this area since his appointment earlier in the year. All staff are now given the opportunity to undertake NVQ training after their three month probationary period. Again staff were extremely positive about this. All staff receive regular formal supervision. The inspector viewed a sample of the supervision notes and found them to be very comprehensive and gave evidence that they encourage personal development. The inspector viewed the recruitment files of the three most recently appointed members of staff. The current recruitment procedure is for staff to work shadow shifts in the home before a Protection Of Vulnerable Adults Check and enhanced Criminal Records Bureau check are applied for. The home must review this practice to ensure that staff do not work in the home before appropriate checks have been carried out. All staff spoken to during the inspection were extremely enthusiastic about their jobs, all spoke respectfully about the service users. The inspector had the opportunity to observe care practices and noted that staff interacted well with service users. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 23 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, 38, 40 & 42. Although the registered manager has only been in post for a very short time he has already made many improvements to the home, including ensuring appropriate training is available for all staff. Appropriate steps have been taken to minimise the health and safety risks to service users. EVIDENCE: The registered manager of the home is Paul Thomas who has been in post for just over three months. Paul has worked with people who have learning difficulties for a number of years and has a wealth of experience in working with people who have autistic spectrum disorder. He has NVQ level 4 in care and level 5 in management. Since joining the staff team he has put in place a number of training initiatives for staff at all levels. He is also providing in house training in areas specific to the needs of the service users. Staff have found this to be very positive. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 24 There is a clear management structure in the home. In addition to the registered manager there is a care manager and a junior care manager. There is a nominated shift leader on at all times. Staff spoken to felt that the management in the home was extremely approachable and stated that their views are always sought and taken into account. There are regular staff meetings and the inspector viewed the minutes of these. Staff stated that they were encouraged to take on nominated areas of responsibility including key working service users. Many stated that the management structure in the home enabled them to see care as a career and that there was support for their personal development. There is a comprehensive folder of policies and procedures which the inspector viewed. Some policies would benefit from being made more appropriate to the service. This was discussed with the manager who stated that there were plans for all policies to be up dated in line with the changing needs of the home. There are clear records in respect of health and safety issues. All accidents and incidents are recorded and the manager audits these on a monthly basis. A fire log is maintained which shows that the fire detection system is regularly serviced by outside contractors and tested in house on a weekly basis. Staff receive training in fire safety when they begin work at the home and there are regular refresher sessions. Appropriate tests have been carried out in respect of the gas and electrical installations. Portable electrical appliances were all tested by a qualified electrician earlier this month. Action has been taken to minimise environmental risks and the possible challenging behaviour of some service users has been considered when furnishing the home. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 25 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 3 4 3 3 x Standard No 22 23
ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 1 3 3 3 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 2 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Holly Tree Cottage Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x 3 x D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 26 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 6 Regulation 15(1)(2) Requirement The manager must ensure that care plans are comprehensive and easily understandable for staff and service users. The home must ensure that all new staff are checked against the Protection Of Vulnerable Adults list before commencing work. Timescale for action 31/08/05 2. 34 19(1) 26/05/05 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. 2. 3. Refer to Standard 13 23 40 Good Practice Recommendations The manager should review the wearing of staff uniforms outside the home in order to assist service users to more easily intergrate into the community The whistle blowing policy should be displayed in the home. The homes policies and procedures should be reviewed to ensure that they are appropriate to the home. Holly Tree Cottage D53 - D02 S58862 Holly Tree Cottage V221752 260505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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