Inspection on 30/01/07 for Hollyacre Bungalow

This inspection was carried out on 30th January 2007.

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

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

Other inspections for this house

Hollyacre Bungalow 18/02/09

Hollyacre Bungalow 29/01/09

Hollyacre Bungalow 23/01/06

Hollyacre Bungalow 25/07/05

Hollyacre Bungalow 07/12/04

Hollyacre Bungalow 27/04/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Hollyacre Bungalow Front Street Sacriston Durham DH7 6AF Lead Inspector Gavin Purdon Unannounced Inspection 30th January 2007 1:10 Hollyacre Bungalow DS0000060040.V324638.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 Hollyacre Bungalow DS0000060040.V324638.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. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollyacre Bungalow Address Front Street Sacriston Durham DH7 6AF 0191 3712020 P/F hollyacrebungalow@talktalk.co.uk 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) Moorland Holdings NE Ltd Miss Sharon Lloyd Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Hollyacre Bungalow is a care home registered to provide care and accommodation for 10 younger adults with learning disabilities. The home does not provide nursing care, but can look after up to 5 residents who have a physical disability as well as a learning disability. The home is located in the village of Sacriston, 3 miles north of Durham City. It is operated by a private company, Moorland Holdings NE Ltd. The accommodation is on 2 floors in a large bungalow converted for use as a care home. There is some outside amenity and parking space, and the home has pleasant views across the local countryside. The current scale of charges for care each week is £378.50 to £721.29 depending on the level of need. The home will arrange additional services for residents if they want them. The home does not charge for this, but the resident pay for these themselves. This would include such things as hairdressing, clothes, entertainment, and holidays. The home makes one additional standing charge per resident of £75.75 each month for transport. Outings are a major feature of life at the home and every effort is made to ensure residents benefit equally from the home’s well used transport service. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is classed as unannounced, and took place with some short notice to the home, to ensure staff and residents would be present at the time planned for the visit. Earlier in this present inspection year the home’s registered manager sent the inspector some useful information about the day to day running and management of Hollyacre Bungalow. Also, with staff help, 3 residents sent some comments about the home from their point of view. A resident’s relative also wrote to the inspector, and this was all helpful background information. The inspection lasted 4 hours 40 minutes and took place on the Tuesday afternoon between lunch and teatime. The inspection was assisted by the home’s registered manager and deputy manager, and by a new member of the care staff team. Few of the residents at Hollyacre Bungalow are able to talk about their care in any detail, but it was possible to meet most of the residents, talk to some of them, and ask staff where residents had been and what they had done that day. Much of the inspection was spent discussing and looking at evidence linked to 3 particular residents as a practical illustration of how care is planned for and provided at Hollyacre Bungalow. What the service does well: Management and staff at Hollyacre Bungalow see the care that residents get as the strong point of the home. Whatever the particular abilities or disabilities of individual residents Hollyacre Bungalow tries to support and provide a good social life and interesting everyday activities for all of its residents. Eating out, day trips, concerts and holidays are regular events. A resident said, “ I’ve been to Turkey for a week’s holiday. It was lovely. I enjoyed myself every day. I enjoyed the aeroplane. I brought my boyfriend a present back.” Staff explained, Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 6 “ The starting point is what the residents want. If they want something we’ll do our best to get it for them, the social life and outings, the meals, the holidays. If someone likes Westlife, we’ll find out where they can see them, or Cliff Richard, Michael Barrimore, or Blood Brother, or whoever.” The management of the home thinks Hollyacre Bungalows is particularly good at providing residents with privacy and independence and that there is a good working relationship between staff and residents based on trust and understanding. A resident said, “The staff always talk to me and ask me what I would like to do each day.” The home is kept very clean and fresh and residents’ bedrooms are very pleasant, very individual, and personalised. What has improved since the last inspection? The management of the home feels the staffing situation has improved. The full staff group is now more settled and this allows for better working relationships with residents and makes it easier to draw up longer term plans such as which member of staff later in the year will definitely accompany which resident on what particular holiday. Management and staff also thought the improved balance of vehicle drivers and male and female staff in the care team had improved the choices open to residents for personal care and for activities. The home has acted on a recommendation that the registered manager complete the final elements of the Registered Manager’s Award. Both the registered manager and deputy manager have now completed the RMA. Following one recommendation the home has taken some action to improve flooring in communal areas and facilities but plans to do more still need to be completed. The registered manager and deputy manager thought the RMA course had helped improve management practice and that checks on the quality of the work at Hollyacre Bungalow were better than they had been. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 7 The home has acted on the one requirement made during the last inspection and replaced its fire extinguishers and provided staff with fire safety training provided by a specialist consultant. 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. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who might be coming to live at Hollyacre Bungalow benefit from assessments that are professionally and sensitively completed. These assessments involve potential residents, and take their own needs and wishes into account. They also involve families and social workers where they can. EVIDENCE: The home has a settled group of residents and there have been no new permanent admissions for 3 years. The care files of the 3 most recently admitted residents were looked at and the topic of choice of home discussed with Hollyacre Bungalow’s registered manager and deputy manager. These files showed that assessments were professionally and sensitively completed, and that residents had been very much involved in that process, and relatives and social workers where at all possible. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 10 A resident told the inspector about how they were involved in choosing a care home, “My Mother and myself came to view the home I am in and we were very happy with it.” Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those residents at Hollyacre Bungalow who know what an individual care plan is, know they can have a say in drawing up that plan and in deciding any changes to the plan. Residents who are able to make their own decisions know that the home will try and help them do that safely. Hollyacre Bungalow will try and help residents to be as independent as they can. EVIDENCE: Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 12 The care files of 3 residents were looked at and the topic of individual needs and choices discussed with Hollyacre Bungalow’s registered manager and deputy manager. The care files and discussions showed that those residents who could be involved in drawing up and changing care plans were involved. The discussions showed that residents who were able could make their own decisions and that Hollyacre Bungalow would try and help residents be as independent as they safely could. A resident told the inspector about being involved with their individual care plans, “ I’m having my review this week. I’m going to be there at the review and I know what I’m going to say.” A resident told the inspector about being involved in making everyday decisions, “The staff always talk to me and ask me what I would like to do each day.” A recent incident in which a resident was injured was looked at. This clearly showed the very practical difficulties of balancing a resident’s wish for independence and the benefits of independence against the possible dangers involved. The home was able to show through it’s care planning and through its risk assessments that it had tried to respect the resident’s wishes and had also tried to reduce the risk of harm involved. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those residents at Hollyacre Bungalow, who are more aware and able, do benefit from active social lives and community involvement. The home works hard to provide for the comfort, pleasure, and safety of those residents less able to do so. EVIDENCE: The care files of 3 residents were looked at and the topic of lifestyles discussed with Hollyacre Bungalow’s registered manager and deputy manager. The care files and discussions showed that the home does try to provide full and stimulating lives. What residents are interested in is important. Efforts are made to help residents have a good life in the home and plenty of time outside Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 14 of the home. Family links and personal relationships are respected and supported. Hollyacre Bungalow’s registered manager and deputy manager described the home’s approach to lifestyle, “ The starting point is what the residents want. If they want something we’ll do our best to get it for them, the social life and outings, the meals, the holidays. If someone likes Westlife, we’ll find out where they can see them, or Cliff Richard, Michael Barrimore, or Blood Brother, or whoever.” The deputy manager explained how one resident’s personal relationship was supported with advice and assistance, involving families and social workers, but protecting privacy and other individual rights. The registered manager described the issues around food for 6 service users, from their enjoyment of favourite foods, to involvement in choosing menus, to health issues and expert specialist dietary support where needed. Examples of menus were also seen, and these looked like substantial, tasty, and varied meals. A resident told the inspector about their lifestyle. They said they could make their own day to day decisions and could do what they wanted during the day, in the evening and at weekends. They also said, “ I’ve been to Turkey for a week’s holiday. It was lovely. I enjoyed myself every day. I enjoyed the aeroplane. I brought my boyfriend a present back.” Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents at Hollyacre Bungalow benefit support based on a good understanding of their personal needs and personal preferences. Residents at Hollyacre Bungalow benefit from staff understanding and meeting their healthcare needs. They also benefit from staff’s wider understanding of residents as individuals when it comes to meeting healthcare needs. Hollyacre Bungalow’s residents benefit from clear medication procedures carried out by trained staff. EVIDENCE: The care files of 3 residents were looked at and the topics of personal and healthcare support were discussed with Hollyacre Bungalow’s registered manager and deputy manager. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 16 The records and discussion showed that the home gathered information on needs and preferences of residents and then built their care plans around these. The registered manager and deputy manager explained how Hollyacre Bungalow cared for many residents with significant physical as well learning disabilities. As such some people had very particular health requirements and these had to be well planned and provided for. In doing so they thought the home did not lose sight of residents as individuals entitled to privacy and independence. The registered manager and deputy manager also thought that whilst it was important to have outside specialist healthcare advice and good in house general healthcare skill and training, it was also important to have a good relationship with and a good understanding of the resident concerned. The registered manager and deputy manager mentioned the improved gender balance in staff at Hollyacre Bungalow, and how that provided a better choice of male carers for the intimate care of male residents and female carers for that of female residents. The arrangements for the safe keeping and recording of medication were looked at. Checks were made against the medication held and recorded as given to a specific resident and these were found to be correct. No service user is risk assessed as being able to administer their own medication without support. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from Hollyacre Bungalow’s general readiness to listen to their views and comments, be those about everyday choices and preferences or occasional concerns and worries. Residents benefit from policies and procedures put in place by the home to protect them. EVIDENCE: 4 residents wrote to the inspector, with staff assistance, and said they knew who to speak to if they were not happy about something, they knew how to complain, and that they were happy with how they were treated by staff. Hollyacre Bungalow’s registered manager and deputy manager gave a good example of how an issue was dealt with regarding the friend of a resident who was under the impression that they were not allowed to visit the home. This was not the case, and the home was happy to explain the position when the matter was raised with them. The registered manager and deputy manager said, “We do listen to people, and we do act. We enjoy consultation and like getting things sorted out.” Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 18 The staff of the home have had training in the protection of vulnerable adults which raises their awareness of protection and what they need to do if they suspect a resident is being abused. Hollyacre Bungalow has its own written procedures for what to do if abuse of residents is alleged or suspected and these procedures were seen during the inspection. These procedures were clear and practical to follow. The home does not have a copy of the most recent local authority adult protection procedures. The home should obtain a copy as they may find it helpful to compare these with their own and to make sure they follow the same processes as far as possible. Money kept by the home on behalf of a resident was checked. This money was safely kept, and the amount balanced against the signed records of money spent and receipts kept. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Hollyacre Bungalow live in a safe comfortable and convenient building. Residents’ safety and comfort are protected by good standards of hygiene and cleanliness. EVIDENCE: The registered manager and deputy manager explained how particular residents benefit from their own specialist aids and equipment, such as their own hoists, commode, bath rails, chair and cups. These are all properly assessed and maintained for the comfort and safety of residents. Some residents’ bedrooms were seen and these were very pleasant and really well personalised to reflect the interests and tastes of each resident. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 20 Hollyacre Bungalow gives residents and their visitors plenty of choice about where they can spend time together, with others, or in private. The standard of furnishing and fittings in the lounge is more basic than in bedrooms but is certainly not institutional, unsafe, or uncomfortable. The flooring and carpeting in some parts of the home’s corridors are showing some wear and tear, with some loud squeaking and small uneven areas of surface in places. The home’s present plans to improve corridor flooring should be completed, taking into account these matters. Action will prevent the situation developing into a nuisance or a hazard in the home. On the day of the inspection the home looked clean and tidy, it had a fresh atmosphere, with good standards of hygiene in the public, private and service areas seen. The registered manager and deputy manager said, “We have good domestic standards. The home is tidy. Staff are trained in health and safety procedures. We have the gloves and aprons, and anti bacterial hand wash.” Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well staffed home, where the staff group has the skills, training, and availability needed to give the care required. Residents are protected by the home’s recruitment and selection practices. Hollyacre Bungalow’s staff are trained and developed to meet the needs of residents in ways that keep residents safe comfortable and happy with their care. EVIDENCE: NVQ in Care qualifications and further specialist training are important ongoing activities at the home. Hollyacre Bungalow’s registered manager and deputy manager have set a particularly good example by both completing the Registered manager’s Award. The home’s registered manager and deputy manager explained how they had managed to set up reliable links with good outside training agencies and thought this was a big benefit to staff and residents. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 22 At the time of the inspection, the home had 9 residents and provides between 425 to 427 care hours weekly. The home’s registered manager and deputy manager contribute 17 and one half hours and 12 and one half hours to this weekly total. Broadly the home works with 3 care staff on mornings to mid afternoon, and 4 on late afternoon and evenings with 4 throughout the day on weekends. Night staffing is 1 carer awake and 1 sleeping on the premises. The present staffing levels help the home to provide individual care for some very dependent residents. At any one time in the day it is possible for the home to support access to day care elsewhere for some residents, to provide outings for others, and to maintain a service in the home for those residents not at day centres or on outings. The personnel file of the most recently employed member of care staff was seen and this contained the information and documents required by the Care Homes Regulations to confirm the suitability of persons working at a care home. Hollyacre Bungalow has sound basic staff recruitment and selection procedures but should review these in the light of current equal opportunities and adult protection best practices. The most recent member of care staff said that they were very satisfied with their experience of introduction to the work, the foundation training provided and the good level of formal and informal support given by management, senior staff, and fellow carers. As a result this most recent member of staff felt more comfortable and in a good position to care for residents in the way that the home expected and in the way that residents wanted to be cared for. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified, competent, and experienced to run the home and this benefits residents and staff alike. The home has clear procedures and practices and management make sures that these benefit residents. Management also makes sure staff know and follow these procedures and practices and gathers views on what residents, relatives, and staff think about the way care is provided and the home is run. The home tries to make sure that the health safety and welfare of residents are considered, and that ways are found to protect residents whilst encouraging independence and choice. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 24 EVIDENCE: Hollyacre Bungalow’s registered manager and deputy manager have both recently completed the Registered Manager’s Award. This has given them both a good opportunity to look at management practice in their own home and to review and develop that practice as part of the award. The home does have a quality assurance procedure. The monthly reports were seen, looking at standards of premises, care of residents, staffing arrangements and general health safety and management practices in the home. Views on these matters were recorded. The home should consider developing these monthly reports to make it clearer when the Responsible Individual, or person delegated to conduct that visit, visited the home, and who they spoke to in the course of the visit. The home’s registered manager and deputy manager outlined the health and safety training and moving and handling training completed by care staff and risk assessments completed for residents in different situations, such as the bathroom and kitchen, were seen. The fire safety records were also seen. These confirmed that checks on equipment had taken place. There was also a record of recent staff fire safety training completed by staff. As such,the home has acted on the one requirement made during the last inspection and replaced its fire extinguishers and provided staff with fire safety training provided by a specialist consultant. As the home has not been visited recently by the fire and rescue brigade, the home should seek current advice from the fire and rescue brigade regarding general best practice on fire safety in care homes. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 X 3 3 X 3 X X 3 X Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA23 Good Practice Recommendations Hollyacre Bungalow does not have a copy of the most recent local authority adult protection procedures. The home should obtain a copy as they may find it helpful to compare these with their own and to make sure they follow the same processes as far as possible. Hollyacre Bungalow’s present plans to improve corridor flooring should be completed, taking into account the small patches of squeaking and uneven surface in corridors. Action may prevent the situation developing into a nuisance or a hazard in the home. Hollyacre Bungalow has sound basic staff recruitment and selection procedures but should review these in the light of current equal opportunities and local adult protection best practices. The monthly reports were seen, looking at standards of DS0000060040.V324638.R01.S.doc Version 5.2 Page 27 2 YA24 3 YA34 4 YA39 Hollyacre Bungalow premises, care of residents, staffing arrangements and general health safety and management practices in the home. Views on these matters were recorded. The home should consider developing these monthly reports to make it clearer when the Responsible Individual visited the home, and who they spoke to in the course of the visit. 5 YA42 As the home has not been visited recently by the fire and rescue brigade, the home should seek current advice from the fire and rescue brigade regarding general best practice on fire safety policy in care homes. Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Hollyacre Bungalow DS0000060040.V324638.R01.S.doc Version 5.2 Page 29 - 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!