Inspection on 20/07/06 for Hollybank House

This inspection was carried out on 20th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hollybank House 19/02/09

Hollybank House 28/02/07

Hollybank House 14/02/06

Hollybank House 20/09/05

Hollybank House 30/03/05

Hollybank House 20/09/04

Hollybank House 30/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Hollybank House Chesterfield Road Oakerthorpe Derby DE55 7LP Lead Inspector Sue Richards Key Unannounced Inspection 20th July 2006 09:30 X10015.doc Version 1.40 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 Hollybank House DS0000002172.V302407.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 Older People. 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. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank House Address Chesterfield Road Oakerthorpe Derby DE55 7LP 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) 01773 831791 Miss Margaret Ann Bradley Alison Jane North Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 4 places for PD over 50 years which are included within the PCN registration 20 places for OPN – within registered total of 40. Date of last inspection 14th February 2006 Brief Description of the Service: Hollybank House provides for up to 40 older persons, including nursing care for up to 20 older persons and up to 4 service users with physical disabilities aged over 50 years. The original house, formerly a private dwelling, was converted and extended for the purposes of registering as a care home. Accommodation is organised over two floors, with access to the first floor via stairs and a shaft lift. There is choice of communal lounge and dining space to the ground floor and adequate numbers of bathrooms and toilets with adaptations to assist those service users with mobility problems. There is level access to well maintained expansive gardens, with seating provided. There are 24 single bedrooms and 9 double, including 3 single and 2 double rooms, which have en suites. The Manager has the support of a team of Registered Nurses, care and hotel services staff and the registered provider has a high profile within the home. An activities person is also employed, who organises a variety of activities for service users, within and outside the home, which are both individual and group based. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a key inspection for this service, which was unannounced. Case tracking was included in the methodology, involving the closer scrutiny of the care of three residents. This included discussions with them and their representatives (as available) and staff about their care, examination of their care and associated records and inspection of their private and communal accommodation. What the service does well: What has improved since the last inspection? A revised format (standardised) for the recording of residents needs assessment and care-planning information has been fully introduced for all residents, which is to a high standard and staff policy guidance and practise in terms of the recording of any verbal order to administer a medicine to any resident has been improved, with clear policy instruction provided for staff within the home’s medicines policy. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 6 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. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Residents are provided with the information they need regarding their choice to live at the home and are not admitted without a full needs assessment being undertaken and are assured that these will be met. Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: Discussions were held with residents case tracked regarding the arrangements for their admissions to the home, including information provided and individual terms and conditions, which they felt to be satisfactory and in agreement with. The Commission has also received resident/relative survey forms, which detail satisfaction in this area. The written terms and conditions for those residents were examined. These provided required detail in respect of their accommodation, care and service provision, fees charged and the arrangements for their payment. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 9 Then individual needs assessment information was examined for those residents case tracked and discussed with them and also with staff. Discussions were also held with staff about the arrangements for their induction and training and records examined. Recorded needs assessments were person centred and included appropriate risk assessment information. Details of individual daily living plans were also in place in accordance with their lifestyle preferences. Staff was conversant with residents needs and staff training arrangements were in accordance with those needs. Residents felt that their needs were well met, although one resident felt he would like to visit home more frequently. This was also discussed with the manager. Highly positive comments were received by residents regarding the care and support they received and also by way of resident/relative surveys received by the Commission. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Residents’ health, personal and social care needs were well accounted for and their health care needs were generally well met, although there were two areas of error in recording in respect of one residents care plan reviews and also within residents medicines administration record (MAR) sheets. Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: The care plans of those residents case tracked were examined and discussions were held with them about their care. Two of the residents had signed their agreement to the care plans. The third resident advised that they had not seen their care plan, but felt they would wish to do so. Care plans were well recorded in accordance with relevant clinical guidelines for the care of older persons, detailing all aspects of their health, personal and social care. They were formulated within a framework of risk management and were person centred. They were up to date and reviews were recorded at monthly intervals. However, for one resident case tracked, their recorded nutritional risk assessment score and previous changes noted in their condition Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 11 by way of the individual weight record, was not reflected in their written care plan reviews, although discussions with that resident and staff indicated that their nutritional needs had in fact been suitably met. Details of inputs from outside health care professionals and the arrangements for these were also recorded for each resident, including for the purposes of routine health screening. The arrangements for the management and administration of medicines were examined for those residents case tracked and were discussed with them and with staff. For the most part, these were satisfactory, although for one resident there were three recent omissions of recording observed on their individual medicines administration record (MAR) sheet and for another, two omission were observed. One the third medicines administration record (MAR) sheet an additional medicines administration instruction was hand written. This instruction was not signed and dated by the person writing it or countersigned and dated by a witnessing staff member. Residents said that staff were respected their dignity and privacy and that “nothing was too much trouble.” Discussions with staff indicated that the promotion of this was an integral part of the philosophy of the care home and staff induction records also reflected this. Feedback from the resident/relative surveys indicated satisfaction with health care arrangements. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 There are satisfactory arrangements to enable residents to participate in activities of their choice and to maintain contact with their families and friends and the local and extended community. Residents are suitably provided with a balanced and nutritious diet in accordance with their individually assessed needs and preferences. Quality outcome in this area is good. This judgement has been made using the evidence available, including a site visit to the home. EVIDENCE: Discussions were held with residents’ case tracked and also the registered provider, staff and other residents about the arrangements for activities, occupation and leisure and their individual lifestyle preferences, including contacts with families and friends. The home employs an activities coordinator. A variety of activities are organised both within and outside the home on a regular basis. These included, indoor board games, regular exercise activities session provided by an outside group, TV, library, entertainers, outings, clothing sales including visits to the local pub, regular in house entertainment and seasonal fetes. A picnic in the park event and treasure hunt were planned. A group of residents were planning a holiday. There is a residents/relatives Committee, who support the home and organise Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 13 regular fund raising activities for the ‘residents fund’, although some residents spoken with were not aware of this. This was discussed with the manager in respect of keeping other residents informed. Menus were displayed prior to each meal. Residents advised that the cook consulted with them all individually on a daily basis regarding their choice of food for the day. The cook was also provided with suitable information as to the individual dietary requirements of residents. These were in accordance with their needs assessment and care planning information for those residents case tracked. All residents spoken with said the meals were very good and enjoyable and that drinks and snack are available at any time. Lunches were served during the inspection. Food was properly presented in accordance with residents’ dietary requirements and individual choices and suitable aids and assistance was provided for those residents who required. Residents own rooms (those case tracked) were highly personalised and two had been involved in their care planning. One of the residents case tracked managed their monies. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There are suitable systems and arrangements in place to enable residents and/or their representatives to complain and to protect residents from abuse. Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: There is a suitable written complaints procedure in place for the home, which is displayed and provided within the service user guide information. Records of complaints received are maintained. One written complaint had been received by the home since the previous inspection, with written notification to the Commission. Records were in place in respect of this, including investigation/action taken and outcome, which was unsubstantiated. During the inspection the manager advised of a verbal complaint and the action being taken in order to investigate this. Residents spoken knew how to complain and resident/relative surveys received by the Commission indicated the same. Residents spoken with felt that any concerns or issues they raised were always dealt with without the need to formally complain. Discussions were held with some staff about the handling of complaints and also recognising abuse and the action to take in respect of any suspicion or direct allegation of the abuse of any resident. Staff was familiar with the Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 15 home’s policy guidance, which was satisfactory and had also received relevant training/instruction. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. Residents live in a well-maintained, comfortable environment, which meets their needs and is suitably equipped and the registered provider is aware of the need to consult with the local Fire Authority regarding the changes to the internal layout and facilities in the home. Quality outcome in this area is good. This judgement has been made using available evidence, including a site visit to the home. EVIDENCE: The private and communal accommodation of those residents case tracked was inspected, together with the laundry. Residents said they were satisfied with their rooms, which were personalised and suitably furnished and equipped in accordance with their assessed needs and personal preferences. One of the bedrooms had an en suite bathroom facility and the others had wash hand basins provided. Showers, bathrooms and toilet facilities accessed by those residents were suitably equipped and clean, although one of the shower rooms was out of action. This was discussed with the manager. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 17 Communal areas seen were well furnished, decorated, clean and comfortable and residents had level access to outside seating areas, which some were using at the time of the inspection. Since the previous inspection, the registered provider has forwarded written notification of a change of use some aspects of the layout and facilities provided by the home. These are almost completed, and include the provision of an additional bedroom, although this is not for use for those residents who receive nursing care or who have significant mobility problems. The registered provider had been advised to consult with the fire officer in respect of these. This had not yet taken place. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Residents core needs were well met by the number of staff provided and overall skills of the staff team, although the provision of individual staff skills analyses and training plans, linked to individual annual performance appraisals in accordance with the home’s policies will provide a more accurate measure as to whether the aims and objectives of the care home are being effectively met. Additionally, recent practise in respect of staff recruitment is unsafe, does not promote the protection of potentially vulnerable adults and is not in line with the home’s recruitment policies. Quality outcome in this area is poor. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: Thirty-nine resident were accommodated at the time of the inspection, including 24 nursing. Details of residents dependencies and needs, together with staff employed and the arrangements for their induction, training (including NVQs) and deployment in the home were provided by way of the pre-inspection questionnaire, including the provision of staff duty rotas for the period 29 May 2006 to 25 June 2006. The arrangements provided by the home for staff induction and training was discussed further with the manager and individual staff and records of these were examined. The home’s policy regarding the induction and training of staff was examined. The induction format was in line with recognised standards and was inclusive of equality and diversity. Records of staff induction were examined for four of the most recent Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 19 staff starters. One of these had not been completed. The staff member had commenced in March, although the manager advised that all documentation must be completed and signed off within 6 months. Although overall training provision was satisfactory, aside from staffs’ initial individual induction and foundation induction training records, there were no individual training plans and profiles updated in accordance with the length of their employment. The home’s policy included annual performance appraisals for staff. These were not being carried out. The recruitment policies of the home were examined, including that relating to equal opportunities. The personal staff records of four of the most recent staff starters were examined. With the exception of one, these did have confirmed CRB/POVA checks and two of the three did not have completed application forms or written references. Serious concerns were raised with the registered provider and manager regarding this with written details provided detailing requirements to be met in respect of those concerns by way of an immediate requirement notice. Staff working in the home came from various cultural and ethnic back ground. The home’s policy stated that equality and diversity monitoring forms were to be completed as part of the recruitment and process. There were none in place in those staff files examined. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 There are significant aspects of good management in the home but management systems are insufficient in that there is no formalised system in operation, which seeks to objectively determine whether the home meets with its service aims and objectives/statement of purpose and policies and procedures and is run in the best interests of residents in formal consultation with them. Although overall safe systems and practise are promoted, record keeping in respect of staff recruitment does not promote their protection. Quality outcome in this area is poor. This judgement has been made using the evidence available, including a site visit to the home. EVIDENCE: The registered manager has been in post for around 2 years. She is a registered general nurse and is undertaking an NVQ level 4 in management. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 21 The registered provider purchased a professional quality assurance and auditing system for the home in September 2005. This is not operational There is no annual development plan in place for the home and no formal mechanisms for consultation with residents or for seeking the views of family and friends and other stakeholders as to how the home is achieving it goals. Residents spoken with were not aware of how to access inspection reports and were not provided with feedback regarding the reports. A number of policies and procedures were examined during the inspection, as referred to under the relevant sections of this report. These were not signed or dated, although those seen were up to date and in line with current legislation. Since 2004 the number of requirements and recommendations made in inspection reports has reduced considerably. A total of 5 requirements and 4 recommendations were made in the last inspection report of 13 February 2006. At this inspection, three requirements were met and three recommendations. Outstanding requirements relate to the lack of an effective quality assurance and monitoring system covering all aspects of the service (timescale 31/08/06) and a formal staff supervision system (timescale 31/05/06). The lack of an annual development plan remains an outstanding recommendation. However, monthly reports were in place from the registered provider, which gave some (limited) information regarding the quality of the home. The arrangements for the management and handling of monies for residents’ case tracked were examined, together with policy guidance in place in respect of these. One resident managed their monies, independently. Arrangements were satisfactory. The staffing structure, skill-mix and staff deployment arrangements were examined and the home’s policy regarding staff supervision was examined. Discussions were also held with the manager and staff regarding the arrangements for staff supervision. Although staff is supervised as part of the normal management process on a continuous basis, there was no system operating for the individual formal supervision of care staff on a one to one basis in accordance with the home’s policy. A variety of records were examined during the inspection process. These are referred to under the various sections of this report. The arrangements for staff core health and safety training were discussed with the manager and staff. With the exception of first aid, these were satisfactory. The home’s policy and arrangements for staff instruction in relation to first aid were not clarified. Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 22 Details of the maintenance of equipment in the home were provided by way of the pre-inspection questionnaire. These were satisfactory. Policies regarding safe working practises were provided in the home, although these were not closely examined during the inspection. Records of accidents/incidents for those residents case tracked were examined and staff were conversant with the home’s policy in respect of the reporting and recording of accidents and incidents. Hollybank House DS0000002172.V302407.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 1 2 2 Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP29 Regulation 17, 19 Requirement Timescale for action 27/07/06 2. OP33 24 (OP37 also applies here). The registered persons must not employ any person to work in the care home, unless they are satisfied that they are fit to do so and have obtained in respect of those persons, information and documents as specified in paragraph 1-7 of Schedule 2. Immediate action must be taken to ensure these are properly undertaken to ensure the safety of all persons accommodated. – written confirmation detailing action taken to be forwarded to CSCI within 7 days of inspection. The formal quality assurance 31/08/06 system must be developed, based on seeking the views of residents in order to measure the success in meeting the home’s aims and objectives/ statement of purpose (and it policies and procedures). NB Original timescale 31/08/06 set at previous inspection 02/06. The registered persons must ensure that care staff received DS0000002172.V302407.R01.S.doc 3. OP36 18 31/08/06 Page 25 Hollybank House Version 5.2 formal supervision at least six times per year in accordance with that specified under NMS 36.3 older persons document. NB From previous inspection for this service 02/06 – original timescale 31/05/06 4. OP38 13 There must be suitable arrangements for the training of staff in first aid. 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations All staff should have an up to date individual training and development assessment and profile/plan as agreed with them. An annual development plan should be in place for the home, informed by formal quality assurance and auditing systems and in consultation with staff and residents. 2. OP33 Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hollybank House DS0000002172.V302407.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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