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Inspection on 28/11/06 for Hollybank Residential Home

Also see our care home review for Hollybank Residential Home for more information

This inspection was carried out on 28th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The atmosphere at the home is welcoming and homely. The manager provides clear leadership and there is a stable and close-knit staff group meaning there is stability and consistency for the residents. The relatives of one recently admitted resident had been well supported during the admission procedure and had formally thanked staff `for making the transition into care a happy one`. There is a commitment to staff training and the staff are knowledgeable about the needs of the residents. There is a system in place for the regular surveying of users of the service as well as other healthcare professionals who visit the home. There is good communication with the residents and their families. Relatives are made very welcome `it is always a pleasure to visit my mum the staff always make us very welcome`; `every member of the staff team are always bright and cheerful`.

What has improved since the last inspection?

The statement of purpose and service user guide have been reviewed and updated to make sure that residents and their families have enough information about the home. The refurbishment of the home has continued involving some of the bedrooms and the communal areas.

What the care home could do better:

The manager has been asked to review the current staffing arrangements. Information gathered during the inspection suggests that residents do not necessarily have a choice about the time they get up or have a bath. Care staff also spend a lot of their time carrying out domestic duties. The manager has been asked to provide privacy curtains in the shared rooms and to make sure that there are systems in place to respect the privacy of residents in shared rooms. The provider must make sure that complaints are investigated within a reasonable timeframe. The refurbishment of the home has not been completed and there remain some areas needing attention for example, some carpets need replacing and some of the bedding seen at the visit was of poor quality.The manager should work with her staff in making sure that there is sufficient detail in the care plans about the specific care needs of the residents. Systems must be in place to make sure that all the doors close properly. Requirements and recommendations have been made to address these issues and appear at the end of this report.

CARE HOMES FOR OLDER PEOPLE Hollybank Residential Home 321 Chapeltown Road Leeds West Yorkshire LS7 3LL Lead Inspector Catherine Paling Key Unannounced Inspection 10:00 28th November 2006 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 Residential Home DS0000001464.V310479.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 Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank Residential Home Address 321 Chapeltown Road Leeds West Yorkshire LS7 3LL 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) 0113 262 8655 0113 2624660 Select Choice Residential Services Limited Mrs Denise McEvoy Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 Brief Description of the Service: Hollybank is situated in the Chapel Allerton area of Leeds with good public transport links to the city centre. The buses stop outside the home and there is also parking available for visitors to the home. The home is registered to provide care for sixteen older people over two floors. There are eight single bedrooms on the ground floor with other rooms on the first floor accessible via a stair lift. Two of the rooms on the first floor are shared and the remainder are single. None have en suite facilities. The communal lounge and dining areas are on the ground floor and are large, comfortable rooms. Personal care only is provided but if nursing input is needed the District nursing service provides support. General Practitioners and other healthcare professionals visit the home when they are required. The home aims to provide a secure, relaxed and homely environment with principals of care focused on the individual needs of residents. Information about the home is provided in the form of a statement of purpose and service user guide. Both these documents were reviewed and updated in April 2006. The current fees charged are from £384 and £406 per week. There are additional charges for hairdressing; newspapers and chiropody. This information was provided by the home in October 2006. Fees are reviewed in April every year. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. More information about the inspection process can be found on our website www.csci.org.uk On some occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. A random inspection of the service was carried out 12th July 2006 in response to concerns raised with the CSCI, which were referred to the provider to investigate. The visit was unannounced and one inspector was at the home from 10:00 until 13:40 on 28th November and between 11:00 and 13:00 on 8th December 2006. The deputy manager assisted on the 28th November 2006 and the manager was available on 8th December 2006. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by residents were visited. A good proportion of time was spent talking with residents as well as with the staff, deputy manager and the manager. The registered manager completed and returned a pre-inspection questionnaire (PIQ) to provide additional information about the home in advance of the inspection. Some survey forms were left at the home providing the opportunity for residents and/or visitors to comment on the home, if they wish. Information provided in this way may be shared with the owner but the source will not be identified. A number of survey forms were returned and comments will be reflected in the body of the report. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager has been asked to review the current staffing arrangements. Information gathered during the inspection suggests that residents do not necessarily have a choice about the time they get up or have a bath. Care staff also spend a lot of their time carrying out domestic duties. The manager has been asked to provide privacy curtains in the shared rooms and to make sure that there are systems in place to respect the privacy of residents in shared rooms. The provider must make sure that complaints are investigated within a reasonable timeframe. The refurbishment of the home has not been completed and there remain some areas needing attention for example, some carpets need replacing and some of the bedding seen at the visit was of poor quality. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 7 The manager should work with her staff in making sure that there is sufficient detail in the care plans about the specific care needs of the residents. Systems must be in place to make sure that all the doors close properly. Requirements and recommendations have been made to address these issues and appear at the end of this report. 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 Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 8 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 Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 9 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 and 3. (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have access to written information about the home to enable them to make an informed decision about moving into the home. All residents have their needs assessed before admission to the home. EVIDENCE: There is a statement of purpose and service user guide available to prospective residents and their families. Surveys indicated that residents and their families felt that they had been provided with sufficient information to enable them to make an informed decision to move into the home. These documents also contain samples of contracts and terms and conditions for the home. All those who returned survey forms said that they had been given a contract. Copies of contracts were seen in the individual care records. All residents have their needs assessed before they are admitted to the home. Trial visits are also encouraged if at all possible. The pre admission assessment seen for one resident was adequate but more specific detail about Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 10 care needs should have been included. For example, where it was recorded that a prospective resident needed ‘full assistance’ with personal care there should have been detail of what assistance was needed. This would clarify why this individual was coming into care and that the home would be able to meet their needs. Once a resident has been admitted to the home a further more detailed assessment of their needs is carried out. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff show a good awareness of residents’ needs and there is good communication amongst them. Care records do not always provide evidence that residents’ needs are met. Overall, residents are treated with dignity and their privacy is maintained at all times. EVIDENCE: Care plans are in place for all residents and a small number were looked at in detail. Overall care plans contained adequate information for staff and there was evidence that residents were involved wherever possible. The format is partially standardised and care needs to be taken in making sure that these reflect detail of individual needs. For example, there was instruction for staff to ‘monitor’ one resident at all times and ‘report any slip in hygiene standards’. Information should be provided to staff about exactly what the resident can and cannot do which will help them understand how and what to monitor with regard to personal care. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 12 Records are reviewed monthly. However there is no regular daily record about the general well being of residents. This was discussed with the manager and she agreed to review the current practice, develop a clear in-house policy of how often a record should be made and make staff aware. Staff are knowledgeable about the care needs of the residents and residents have confidence saying ‘staff know what I like’. The input and assistance of other healthcare professionals is sought whenever it is needed. The manager is also clear about when to seek re-assessment of care needs if she feels that the home can no longer meet specific needs of residents. This can be either due to mental health problems or because they need more nursing care input than can be provided by the district nursing service. Observation and discussion showed that staff clearly respect the privacy and dignity of residents. However the lack of proper screening in shared rooms does provide the opportunity for privacy and dignity to be compromised at times. Staff involved in the administration of medicines are properly trained. They are currently part way through a course entitled ‘At Home with Medicines which is being run by the local pharmacist in conjunction with the Primary Care Trust (PCT). Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall residents’ choices are respected and contact with family and friends is encouraged. A good and varied diet is provided taking into account residents’ choices. EVIDENCE: Social care plans were seen in the individual care records looked at which included typed detail of what the residents liked to do. There was no evidence within the files that theses had been reviewed and what specific activities residents had taken part in. A social diary was held centrally which recorded such detail. This information should be recorded in individual files. Information received from surveys suggested that some residents did not always feel that there were activities arranged at the home that they could take part in. Staff work instructions included activities within the daily tasks. There are trips out for the more able residents, monthly entertainers and in-house bingo and quizzes are examples of activities and stimulation provided. A religious Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 14 service is held at the home on a regular basis and people are able to take part in this if they choose to. Residents said that relatives are welcome at the home and are able to visit at any time. The relative of one recently admitted resident had written to thank the manager and her staff ‘for making the transition for Mum and I into your care, a very happy experience’. Although some preferred times of going to bed and getting up were recorded in records work instructions for staff suggested that these might not necessarily be adhered to. For example, work instructions for the night staff clearly state ‘05.45 – Wake and sit all residents up and serve them a cup of tea in their bedroom’. These instructions also state ‘06.00 till 07.00 – begin bathing and dressing the upstairs residents and take them to the lounge when ready’. Such instructions do not support person centred care and residents choice. One of the three carers on the morning shift also works in the kitchen, preparing the breakfast and the lunchtime meal. She is well aware of the nutritional needs of the elderly and the specific likes and dislikes of the residents at the home. Residents are consulted about what foods they would like on the menu and some have recently asked that tripe and beef dripping be served. There was a choice provided at the lunchtime meal. Residents were served generous portions and were seen to be enjoying their meal. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall complaints are taken seriously. Residents feel safe living at the home and staff are aware of adult protection. EVIDENCE: The home has appropriate policies and procedures in place to deal with complaints and adult protection. Following the random inspection in July 2006, a recommendation was made to review the procedure. This was to include response timescale and also information that the complainant would be informed if the investigation was to take longer than 28 days. There has been one complaint received by the CSCI since the last inspection that was forwarded to the provider for investigation. There had been a delay by the provider in responding to the complaint and this had resulted in the random inspection of July 2006. At the time of writing the report the provider’s investigation had been concluded and a response sent to the complainant. A record is kept of all complaints received and the action taken. Residents, family and friends are able to access the complaints procedure easily as it is contained in the Service User Guide. All of the people spoken to during the inspection said that they are able to speak to the manager or staff if Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 16 they have any concerns or worries. Staff have received training in adult protection and there is a whistle blowing procedure in place. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 17 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, 23, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some work has taken place to improve the environment but further work is required. EVIDENCE: All areas of the home used by residents were visited during the inspection. Generally bedrooms are comfortable and suitably furnished but there were two rooms in which the carpets were badly stained and in need of replacement. The manager said that these had already been identified and were to be replaced soon. There are some shared rooms that were not fitted with privacy screening. There was a damaged mobile privacy screen in one shared room but the manager said that in practice this was not routinely used. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 18 There are no en suite facilities and there are communal assisted sanitary facilities available for residents. The bath on the first floor was very low and the provider should consider replacing it as part of the ongoing refurbishment in the interests of health and safety of the staff involved in assisting residents in the bath. The quality of bed linen seen was variable with some sheets worn and ill fitting. The manager also acknowledged that the standard of bed making was also sometimes variable. There is a sluice room on the ground floor. There was no soap or paper towels at the washbasin in this area. Bar soap was seen at several washbasins in communal areas. In the interests of infection control bar soap should not be used and paper towels should be provided. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are trained and competent to meet the needs of the residents although they do not have the support of ancillary staff. There are good recruitment procedures in place to protect the residents. EVIDENCE: The manager and her staff are a stable team who are supportive of each other providing continuity and stability for the residents. There are three care staff rostered to care for the current occupancy level of fourteen residents. One of these carers is assigned to the kitchen, as there is no dedicated cook employed. There are no domestic staff employed. There is one waking and one sleep-in member of the night staff. The manager said that since May this year the day staff start one hour earlier and the ‘sleep-in’ carer works from 07.00 until 08.00 to get residents up and bathed. The manager works five days a week and provides on call cover over twenty-four hours. Staff work instructions are displayed in the kitchen and it is evident from these that both day and night staff spend a great deal of their time carrying out domestic cleaning duties. The manager has been requested to review the staffing arrangements with regard to the provision of ancillary support for carers. As part of her review she has been asked to provide a breakdown of how staff divide their time between domestic and caring duties. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 20 Training is important at the home and staff can access relevant courses and all spoken with felt they were given plenty of training opportunities. Staff are working towards National Vocational Qualification (NVQ) in care at level 2 but the home has yet to achieve the level of 50 with NVQ level 2 or above. The recruitment records were looked at of recently employed staff and overall procedures were satisfactory and the necessary checks were carried out. Records of interview were not kept in all cases and this was recommended as good practice. Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed; the interests of the residents are important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has many years experienced working with older people. She has completed NVQ level 3 in care and is working towards the Registered Manager’s award. Staff and residents spoken to all feel that she offers them good support and is ready to listen to ideas they may have. Everyone spoken to said they are happy to speak to her if they have any concerns or worries. Staff meetings are held monthly with the most recent held on 24th November 2006. Christmas arrangements were amongst the topics discussed at this meeting. The manager also holds monthly meetings with residents. In Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 22 addition, in-house questionnaires are circulated on a three monthly basis to seek views on the service from residents, relatives and healthcare professionals involved at the home. The manager said that she also holds relatives meetings but does not keep records of these; she was advised to do so. The provider does carry out regular visit to the home as required but does not always make his reports available to the CSCI. Although no doors were seen wedged open at this visit a number of doors did not effectively close. The manager was advised of this and was in the process of addressing this. The home does not handle residents’ finances. Hollybank Residential Home DS0000001464.V310479.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 2 X 3 2 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X 3 2 Hollybank Residential Home DS0000001464.V310479.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 OP12 Regulation Requirement The provider must make sure that there are systems in place to facilitate staff in respecting the privacy and dignity of the residents in the shared rooms by means of privacy curtains. 02/04/07 The provider must make sure systems are in place for all residents to be able to make choices and have control over their lives. The provider must make sure all complaints are investigated within reasonable timescales. The carpets identified to the manager at the inspection must be replaced. Suitable bedding must be provided for all residents. The provider must review the staffing numbers and skill mix of staff to ensure that these are appropriate to the assessed needs of the service users, the size, the layout and purpose of the home, at all times. Care staff must not be taken DS0000001464.V310479.R01.S.doc Timescale for action 12(2)(3)& (4)(a) OP14 2 3 OP16 OP24 22 16(c) 19/02/07 05/03/07 4 OP27 18 02/04/07 Hollybank Residential Home Version 5.2 Page 25 5 OP28 18 away from caring duties to carry out domestic tasks. There must be sufficient ancillary staff to support the care staff. At least 50 of staff must be qualified to NVQ level 2 or equivalent. Timescale of 31 December 2005 not met. The manager must complete the Registered Managers Award within the set timescales. Timescale of 31 December 2005 not met. The provider must make sure that all doors close properly and effectively and part of the fire safety precautions. 31/03/07 6 OP31 9 31/03/07 7 OP38 23(4) 12/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The individual care plans should be further developed to make sure that they provide staff with clear and specific instructions about care. There should be a clear in-house policy regarding daily records/progress notes. The refurbishment of the home should continue to make sure that residents live in a comfortable and wellmaintained environment. The provider should give consideration to replacing the very low bath on the first floor in the interests of the health and safety of staff assisting residents in using the bath. 2 3 OP19 OP21 Hollybank Residential Home DS0000001464.V310479.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Residential Home DS0000001464.V310479.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. 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!