Inspection on 18/07/07 for Hollybrook House

This inspection was carried out on 18th July 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollybrook House 07/01/09

Hollybrook House 09/07/08

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Hollybrook House 85 Silver Road Norwich Norfolk NR3 4TF Lead Inspector Ruth Hannent Unannounced Inspection 18th July 2007 09:30 Hollybrook House DS0000069241.V346459.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 Hollybrook House DS0000069241.V346459.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. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybrook House Address 85 Silver Road Norwich Norfolk NR3 4TF 01603 767578 01603 611620 hollybrook@swantoncare.com 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) Swanton Care and Community Ltd Care Home 43 Category(ies) of Learning disability (15), Mental disorder, registration, with number excluding learning disability or dementia (43) of places Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Hollybrook House may accommodate up to forty-three (43) service users of either sex aged between 18 and 65 years who have a mental disorder. Up to fifteen (15) services users may also have a learning disability. The conditions and safeguards for this condition are as set out in a letter from Andrew Frederick Care Homes Ltd to the Commission dated 2nd September 2003, a copy of which is on file. These 15 service users are included within the overall total of 43 service users. 4 named residents who are now over 65 years of age who have resided at this Home for a number of years. 3. Date of last inspection Brief Description of the Service: Hollybrook House provides care and support to up to 43 adults with mental health needs, some of who may also have learning difficulties. The resource consists of a main house catering for up to 12 people and a series of shared houses and flats that offer the opportunity for more independent living. Hollybrook House is located within walking distance of Norwich city centre. Fees – £307 - £1600 Website address - www.swantoncare.com Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been completed after a visit to the Home that took place over a period of six hours. Information has also been used from the previous inspection of October 2006 and also from the Annual Quality Assurance Assessment (AQAA) that was completed by the General Manager before this site visit. During the visit many residents and five staff members were spoken to that included two Senior Carers, the Manager, the Cook and the Administrator. Pre inspection comment cards had also been sent to residents and next of kin but nothing had been returned to the Commission. A tour of the building took place and some records were looked at that included care plans, medication procedures, daily records, personnel files, staff training records and supervision notes. The Home has had a lot of changes over the last few months that include a few personnel changes as well as the imminent building works that has taken some time for the plans to be agreed by the local planning authority. The Home is now beginning to settle after so many changes and moves to improve the service are beginning to take place. What the service does well: The residents have all been living in the Home for at least a year and all appear content with their lives. The meals remain varied and offer individual choice. Residents’ privacy is respected and all residents have individual rooms that can be locked. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to admission. History tells us that no one is admitted if it is seen that the service offered is unable to meet the need of the individual but as no one has been admitted for some time and a new Manager is now in place the quality of a current assessment could not be judged. EVIDENCE: The Home is going through many changes at the moment with the provider of the service now owned by Swanton Care. The paperwork throughout is slowly being updated and although policies and procedures are in place the newer versions written by Swanton will shortly all be in place. The Home has not admitted any new resident since the last inspection and assessments within residents care plan documents are still in place. Residents appear to be suitable for the service offered at Hollybrook and through observation and on talking to a Senior staff member there was one placement that had to be cancelled with the person moving to a more secure environment in the last twelve months. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The outcomes for the residents are adequate although individual needs and choices could be improved further when the Home begins to move from institutionalises ways and focuses more on stimulation, ideas and goals that will suit the residents on an individual basis. EVIDENCE: The Home works with the residents and the professionals involved to build a care plan based on the decisions by the resident, family and professionals. Reviews are now taking place, which was not the practise before and the new Manager is actively seeking professional support for the residents to be more involved with the individual reviews. The staff talked to showed the Inspector the care plans of three residents who had documents in place. With the transition of one set of formats to another (Barchester to Swanton) it was difficult to track a resident to ensure the needs were tailored to the individual. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 10 A senior staff member is about to carry out a complete new care plan, which was discussed in full with the care plan folder ready and waiting with all the relevant paperwork inserted. Once this care plan has been written with the resident then other care plans will follow with all plans written on Swanton paperwork that is fully geared towards mental health needs and all should be completed in the next three months. Throughout the day it was evident that people lead the life they choose. Many of the residents have lived at Hollybrook House for a number of years and have slipped into behaviour that appears institutionalised. Noted were people arriving with plate and dish to collect lunch at a set time. In the morning people were just sitting around with no aim. The individual person centred approach with outcomes and goals does not happen for everyone to date but has been recognised by the Manager now in post (mentioned in the AQAA and on the day of the visit) who is actively planning ways to improve the outcomes for each person. Each resident has some risk assessments in place. On talking to two residents they were very aware of the risks that involved them and how the home staff help them manage that risk. On the day of the inspection one person was receiving a small amount of money that is issued in amounts that ensure the spending is done appropriately. The risk assessment was in place and all the relevant financial paperwork was signed by the member of staff and the resident as the money was handed to the person. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The outcome is good as the Home and residents develop more contacts and get more ideas on how to occupy their time. Staff do now treat residents with respect and allow choice in their daily lives. EVIDENCE: Until recently the residents had very few activities that happened on a daily basis to stimulate, occupy and encourage them to be more involved. Now there are art groups, gardening and competitions, and residents are gradually encouraging residents to be more involved. One gentleman talked of his fortnightly cooking sessions in one of the flats to practise cooking skills. This is a slow process as some residents have got into set ways, do not want to join in and would rather just sit or smoke. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 12 Those residents who are able do go out to voluntary work or day centres do appear to enjoy what they do. One resident talked about his days at the local garden centre with enthusiasm and appeared very contented. Residents do come and go to the shops, pub and cinema. A group of people went to Great Yarmouth for a caravan holiday and had a good time. One resident was keen to show photographs of recent outings that were obviously enjoyed. On the notice boards in all areas it was noted that quite a few trips were planned. With the use of the people carrier vehicle the residents do appear to get out and about fairly regularly. The Manager has recently been finding out where all the different churches and places of worship for different beliefs are throughout Norwich and is to discuss all these options with the residents so they can choose if they wish to visit any of them. (This was also noted in the assessment document submitted by the Manager) Two people have already visited the church next door. One gentleman was spoken to who likes to visit churches and would also like to know more about other types of worship. Some residents have little or no contact with their families. The Manager is now collating information to encourage the residents to send birthday and Christmas cards to their families to try and keep in touch with them. No visitors were seen on the day and very few entries are made in the visitors book. (The Inspectors name was the first one for a week). Throughout the tour of the buildings it was noted that all bedroom doors were knocked on before entering. Each resident has a key to their own room and no one entered without being invited in. One room seen was a shared room and unfortunately offered very little privacy for the two people sharing. Residents were seen freely walking around the buildings and grounds as they wished. People who like to be alone also are allowed that choice. Some time was spent talking to a resident who has very little in his room and spends quite a lot of time in it. It was discovered on questioning that this was obviously his choice and how he had lived for many years. The meals and mealtimes are very institutionalised. There is lots of choice available but served from a hatch in the main house with residents still carrying hot food outside and across to their own house. This has been mentioned on previous inspection reports but hopefully will now be resolved with the completion of the new building being constructed very shortly. (Plans have now been passed and work to demolish of the old building starts five days after the date of this inspection). It was also noted that staff were having a full days training and having to use the dining room as a training room with residents waiting outside until all the training for the morning had been completed. (The new plans should also incorporate a training room to prevent staff from intruding in the resident’s own space). Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. These outcomes do need to be improved if residents are to have safe medication procedures in place and have personal support in a way that is preferred. EVIDENCE: At present very little personal care support is given. On walking the building it is apparent that some residents do need an approach from staff that will be received in a way that will encourage them to bathe, cut their mails, wash their hair and change their clothes. Some residents may choose to look a little unkempt but this should be the exception and not the rule. (Recommendation). A clear understanding of mental health needs is required by some staff so that expertise can be used to offer guidance and support to encourage cleanliness of individual residents. There was no evidence written in care plan documents telling of different approaches to show how a person is encouraged and what tactics work and what don’t. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 14 The Home has all the residents registered with one GP practice. The support they get from this practice is very good. The one Senior staff member spoken to told of the three doctors all being helpful along with the Community Nurses who call in to Hollybrook as and when needed. The self-assessment document mentions a chiropodist who calls regularly and this was also detailed in the daily notes of a resident. The medication is now stored in a lockable trolley in a locked room, which is much improved than on previous visits. The Boots blister pack system is in use and is a much safer practice. On checking the recording on MAR charts it was noted that some signatures had not been placed on the record when medication had been administered. (Requirement). It was also noted that one medication that could be taken as required was short of one tablet and due to the difficulty of recording PRN for this individual some format for this PRN medication needs to be in place that suits the requirements of this person. (Requirement) Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. These outcomes are much improved with residents now listened to and action being taken on complaints. Staff do understand the signs and symptoms of abuse and how to ensure residents are protected. EVIDENCE: The Commission had received a complaint from a resident. This was shared prior to the inspection with the Manager, who has carried out a full investigation. The recordings of the event are stored on the Managers computer and the letter sent to the complainant was seen both prior to the inspection and again on this visit. The Inspector also wrote to the complainant and has heard nothing in reply. Unfortunately the resident in question was away for the day during this site visit so no contact was made to ensure the outcomes from the investigation was as expected. The Manager did say that she had seen the person again and that they were happy with the results. In all areas of the complex the Manager has also placed folders on the wall for all residents to place compliments, comments and complaints. These have only just been implemented and as yet have not had any comments placed in them but are to be introduced further at the next residents meetings. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 16 Since the last inspection all staff have attended a full days training on the Protection of Vulnerable Adults. (Dates seen on training certificates as January 2007). The staff are aware of the whistle blowing procedures. On questioning one staff member she did understand the signs to look for but was not clear on the procedure to take if abuse was suspected. (Recommendation). Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents do not all live in a homely comfortable environment but the areas are safe and will be improved with the refurbishment programme. EVIDENCE: Hollybrook House is spread over a large site and has a variety of different types of accommodation from flats to single rooms to sharing a house that vary in different of age and quality. The Home has had very little improvement carried out over the last few years as plans to develop the site have been pending for a while. After many various plans had been presented to the Council the work is now about to start and demolition begins within a week of this inspection. Therefore a full inspection of the environment did not take place on this occasion. The gardens have improved and there are now pathways with handrails making the access from house to house better. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 18 A walk of some parts of the property did take place with many areas seen as needing updating. The main house has a very institutionalised shower and bathroom. Shower curtains were held on by three hooks and had a permanent drip from the hose causing a stain on the flooring. The window panels are still in the door and although covered by a white curtain it is still not suitable for privacy when the light is switched on. Two areas in the ceiling of two bedrooms have had some form of leak from the guttering outside which has left a flaky, marked area. One shared bedroom has a dividing curtain that, when drawn covers the one centre light so the one person would have limited light. The bulb had no shade on and the curtains were not hooked up properly. On discussing all these concerns with the Manager a plan of re decoration with fabrics and carpet selections were sitting on the table (seen) waiting for the choice from the Manager of the upgrading of many areas in the house. The plan is, as the new build is in progress, the rest of the property will be improved to be in keeping and in a decorative style to match the new extension. There is no odour in the Home and areas seen were clean. A temporary arrangement for personal clothing is being sought from an outside laundry agency with linen to be washed in the small machine in the main house. This is to be monitored closely to ensure this system can meet the needs on a temporary basis. (The existing laundry, which was not really suitable, is being demolished). Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The levels of staff in the Home do not meet the needs of the residents at all times. Personnel procedures are safely carried out and training has improved to ensure residents are cared for by a qualified staff team. EVIDENCE: It has been recognised by the new Manager and also by the outcomes of the Homes quality checks that the staff team need to have a clear understanding of mental health to be able to assist a resident to meet their full potential. The qualities of the staff team as identified in Standard 32 of the National Minimum Standards is not fully in place but good quality mental health training is in the plans for the next few months. (Requirement) Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 20 The self assessment document talks of trying to recruit more staff and on discussion with the Manager the adverts have requested NVQ qualified staff only to apply. At present there are only 14 full time 2 part time staff in total who are covering 620 hours of care per week. The staff team on the day of the inspection were running with only three care staff with then at four o’clock only two staff on duty and the rota is planned to have five staff all day. (One more member for the late shift was found who was offering to stay late after a full training session day). The constant use of obtrusive, noisy radio hand-sets to summon assistance or get someone to take a phone call was not pleasant and quite institutional. The Home must ensure enough staff are on duty to cover the wide spread area on the site and consider the privacy and confidentiality of residents. (Requirement). It was also noted that the Home only has one housekeeper from 9 to 3 on Monday through to Friday. The Home has no other domestic help and as this person was on leave the week of the inspection, care staff were also having to do more domestic chores than usual. (Requirement) Two personnel files were seen and held the relevant documentation, including training records and supervision notes. All staff have been POVA and CRB checked. The administrator has worked out a system to ensure all paperwork is in place and locked in the filing cabinet in the office. The self assessment document listed many training sessions that have already taken place or are planned for the next year. The staff were behind in their statutory training last year but a new list of who needs what and when is now beginning to happen. On the day of the visit a number of staff were in for the day being trained on health and safety. During their break they were spoken to and all of them appeared to be enjoying the learning taking place. The number of staff who are aiming for the NVQ qualification is 7 with 4 staff already holding NVQ 2 and above. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are beginning to benefit from a well run home with the health, safety and welfare of residents and staff protected. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 22 EVIDENCE: Hollybrook now has a Manager who has a number of years experience managing this type of service and who has just completed her Management award and is awaiting the certificate. Although she has only been in this Home for four months, already an improvement is showing with many management tasks now being carried out. The staff team who were spoken to feel that the Home is just beginning to settle and people are beginning to focus again. The Home has been through and is still going through a lot of changes but with good management at the helm the team are feeling better. (This was mentioned by both the Senior and Administrator). A new set of quality questionnaires have been written by the Manager to ask questions of both residents and professional stakeholders and are about to be distributed. (seen) These will be used as part of the process of measuring the quality of the service but some questions need to be re thought and to not include closed questions where people just answer yes or no. (Recommendation) Besides these questionnaires the company also has a quality checking system on a monthly basis (seen) concentrating on an area of the service such as health and safety or care plans. This information is collated by head office and then an action plan is drawn up with deadlines for completion to improve the outcomes. When this manager took over many of the records were out of date for the servicing of equipment. A big effort has been made to get all the servicing up to date with the gas appliances annual service dated 06/07 and fire equipment also 06/07 were picked at random to check. Although the staff were having training on the COSHH regulations on the day of the visit the safety data sheets were not in sight and should be held where the cleaning chemicals are stored. (Recommendation). Accident forms are all in place but noted on one was a fall approximately two months ago of one resident who ended up with a broken foot. The Commission was not notified of this accident, which should be reported under Regulation 37 of the Care Home Regulations. (Requirement). The Staff have over the years received various forms of induction. The Manager is about to introduce Skills for Care to all staff, old and new, to ensure all staff are up to date with aspect of their job. Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 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 2 3 2 x 3 x 3 x x 2 x Hollybrook House DS0000069241.V346459.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 YA32 Regulation 18.1 (a) Requirement The registered Manager must ensure at all times suitably qualified staff are working within the Home. (Outstanding requirement) The registered Manager must ensure that competent staff are working at the Home in such numbers as appropriate for the needs of the residents. Carers and Housekeepers. (Outstanding requirement) The Home must ensure that at all times initials or a code is placed on the medication administration record sheet at all times of administration. Residents who are taking medication when required must have an appropriate recording sheet for all PRN medication. All serious injuries must be reported to the Commission. Timescale for action 01/10/07 2 YA34 18.1 (a) 01/08/07 3 YA20 13.2 01/08/07 4 YA20 13.2 01/08/07 5 YA42 37.1 (c) 01/09/07 Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA18 YA23 Good Practice Recommendations Staff need to have the skills to encourage residents to manage their personal care. The staff should know who and how to report concerns of potential abuse as all have just received training. More effort in ensuring staff have clear instructions needs to be in place. The quality assurance questionnaires could be further improved with more open questions. It is good practise to ensure all COSHH safety data sheets are stored in the locked area where all the cleaning chemicals are stored. 3 4 YA39 YA42 Hollybrook House DS0000069241.V346459.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Hollybrook House DS0000069241.V346459.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. 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