Inspection on 02/08/06 for Hollydale

This inspection was carried out on 2nd August 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollydale 03/10/08

Hollydale 07/02/06

Hollydale 28/09/05

Hollydale 28/02/05

Hollydale 06/09/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Hollydale Back Lane Clayton Le Woods Lancashire PR6 7EU Lead Inspector Val Turley Unannounced Inspection 2nd August 2006 09:30 Hollydale DS0000006000.V297605.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 Hollydale DS0000006000.V297605.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. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollydale Address Back Lane Clayton Le Woods Lancashire PR6 7EU 01772 337701 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) Dalesview Partnership Miss Michelle McMillen Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 8 service users requiring personal care who fall into the category LD - Learning Disability. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 7th February 2006 Date of last inspection Brief Description of the Service: Hollydale is one of three homes situated on the same site. They are owned and managed by the Dalesview Partnership. Hollydale is currently registered to accommodate eight service users with a learning disability and who may also have a physical disability. The home primarily offers long-term care. The home stands in its own grounds and has open views to two sides. The building is a single storey purpose built establishment, with wide doorways and easy access throughout. The home consists of eight single bedrooms, which are all individually furnished, a bathroom and shower room, which have been specifically designed to provide a suitable environment for assisting clients with physical disabilities. There is also a large spacious lounge, dining/activity room and kitchen which clients may access with relevant supervision. In addition there is a laundry and office. There are communal gardens shared by two of the homes. These have been landscaped to the front and side and offer a sensory area. There is also a large patio to the rear. The home is situated in Clayton-le-Woods on the perimeter of a housing estate. There are a range of facilities including a supermarket, library, leisure centre, public houses and park within walking distance which the home accesses. Clayton-le-Woods is situated on the A6 which is the main road linking the city of Preston and the market town of Chorley. This means the service users also have access to the facilities offered in these towns. The basic fee at the home is £750. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection of a service takes place over a period of time and involves gathering and analysing written information. A site visit was also made to the home as part of the inspection process and this involved discussion with a service user, discussion with visitors and staff, observation of the staff working there, an examination of records, policies and procedures and a tour of the premises. A questionnaire was completed by the manager prior to the site visit. Comment cards were received from relatives and health and social care professionals involved in the service. These provided information that was included in the report. As part of the inspection, the inspector used “case tracking” as a means of assessing some of the National Minimum Standards. This process allowed the inspector to focus on one of the service users living at the home. Records relating to that individual were inspected, as the service user had communication difficulties, staff were observed providing individual support to the service user, discussion with the support staff took place. During the course of the site visit, discussion took place with other service users were this was possible. What the service does well: Hollydale provides a clean, comfortable, homely and well-maintained environment for the service users living at the home and the staff who work there. The home had a good approach to admitting new service users to the home, ensuring they had enough information to enable them to make a decision as to whether they could meet their support needs. Relatives where given lots of information about the service, helping them to make an informed decision about their choice of home. Care plans were very detailed and outlined clearly the service users support needs and preferred routines of personal care. Support staff were very aware of how service users should best be supported. Relatives, independent advocates and health and social care professionals were involved in the development of the plans. Person Centred Planning had commenced for the service users living at the home with the aim of ensuring that service users were supported to achieve their identified goals. The home worked hard to ensure that the service users enjoyed a positive and fulfilling lifestyle, enjoying a range of activities. Service users were involved in conversations and they were also supported to spend time alone in their rooms if they wished. Meals were varied and appeared to be nutritious; these were planned according to the preferences and dietary needs of the service users. The home had a good relationship with families and they were welcome to visit at any reasonable time. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 6 The health needs of the service users were attended to appropriately with staff having a good knowledge of service users health support needs. A number of health and social care professionals were involved in the home and comment cards received from two of these indicated that they were satisfied with the care and attention that service users received. Relatives of one of the service users described the staff as being ‘wonderfully supportive and caring’. Staff were recruited appropriately and were well supported by senior staff and management at the home. There was a range of training opportunities on offer for them and as a staff team they had a range of skills and knowledge. Over half of the staff team had either achieved or were working towards a nationally recognised qualification in care. The staff were well motivated and respected the privacy and dignity of the service users. The manager of the home manager had the relevant qualification and experience to run the home well. She was motivated and enthusiastic in her approach and was keen to ensure that the home met the Care Home Regulations and Standards. The home undertook a number of quality assurance audits to help maintain the good service provided. Health and safety training was provided for all staff and there were risk assessments in place for all activities undertaken with the service users and for all working practices. What has improved since the last inspection? Since the last inspection the manager has worked hard to improve the standard of care at the home and to meet any requirements or recommendations made at the last inspection. The support of the staff team has improved and a number of incentives have been developed to encourage staff to work positively and effectively. A newsletter had been produced and sent to all those involved in the service, this outlined the results of the service users and families satisfaction surveys. The home had reviewed and updated a number of policies and procedures since the last inspection. These were the policy dealing with personal and sexual relationships, the medication policy, the vulnerable adults policy and the physical intervention policy. Health action plans had also been developed for each of the service users to enable them to address any health issues in a structured way. They had developed additional guidance for each of the service users in relation to issues of consent to medication, how medication should best be administered to them and the action to take if medication is refused The staff rota had been developed to identify the capacity of staff working on any one shift and those members of staff who had received specific training, helping to ensure that there was always a member of staff on duty with these skills. Since the last inspection the manager had begun to analyse all accident and incident records so that any pattern or trends could be identified and managed. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 7 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. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. 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. The home had a good and thorough approach when admitting new service users ensuring as far as possible that the choice of home was suitable. EVIDENCE: There had been no new service users admitted to the home since the last inspection. The file of one of the established service users was examined and this contained information from a variety of resources, indicating that the home had received enough information to enable them to make a decision as to whether they could meet the support needs of the service user. A care plan had been developed based on the information obtained through the preadmission and assessment process. Visiting relatives spoken to on the day of the site visit to the service stated that they had found their introduction to the service informative, enabling them to make an informed decision about their choice of home. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual needs were met and they were supported to make individual decisions and choices. EVIDENCE: The file of one of the service users was examined in detail. The support needs of the service user were clearly outlined in the care plan, which also included details of the service users individual preferences as well as established and preferred routines of personal care. Discussion took place with the service users key worker who demonstrated that she had a good knowledge of the service user and how their support needs should be met. Observation of the staff supporting the service user demonstrated that they were following the guidance in the care plan. Care plans were drawn up in conjunction with family members where possible and independent advocates supported two of the service users. The plan examined had been reviewed regularly at appropriate intervals and included details as to how the service user was to be supported to make choices and decisions. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 11 Comment cards received were received from four families and these all expressed their satisfaction with the service. The care plans at the home were gradually being introduced in a format that was more accessible to the service users. All activities that the service user took part in were risk assessed enabling them to participate in these as safely as possible. It was recommended that the home explore the possibility of supporting service users to attend a self advocacy group, or possibly look at establishing a forum for the service users resident at the four homes in the group allowing discussion to take place around agreed themes. The home had commenced Person Centred Planning with the service users living there with the aim of ensuring that service users were supported to achieve their identified goals. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users were supported to enjoy a positive and fulfilling lifestyle. EVIDENCE: The home had put a great deal of effort into creating a positive lifestyle for the service users living at the home. The care plans included information regarding the service users interests and hobbies and the staff spoken to were aware of these and supported service users to become involved in activities both in the home and in the community. Discussion with the parents of one of the service users living at the home indicated that the activities arranged were varied and frequently arranged. A local college had been approached and attendance at courses had been successfully arranged for some of the service users. It was recommended that the home work towards placing more emphasis on community inclusion in terms of the activities the service users participated in and a move to get involved in more mainstream activities. One of the service users was able to talk about his visits to the pub and trampolining sessions. The service user whose care was tracked was seen to be supported by staff to participate in activities identified in the care plan as being the service users hobbies and interests. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 13 To encourage support staff to appreciate the experiences of service users living at the home and their dependency on staff for day to day support, they were encouraged to spend a significant period during the course of one day in the role of a service user and to rely upon the staff team for support in a variety of activities, including being fed. The manager felt that this was a positive experience and that the staff had benefited from it, giving them a better understanding of service users needs. Discussion with visitors and staff and information recorded in service users files, indicated that the home worked hard to help service users maintain contact with their families. Visitors were able to visit at any reasonable time. The management team stated that they were committed to improving the contact that they had with families and the recently introduced newsletter was part of the planned improvements. The visitors spoken to said that they had appreciated the newsletter interesting and found it interesting. The service users enjoyed freedom of movement around the home. Staff involved service users in conversations and supported service users to spend time alone in their rooms if they wished. The care plans included detail to enable this to happen safely. Staff respected the service users privacy and dignity and were observed to knock on bedroom doors before opening them and to discuss choices and decisions with service users. It was recommended that the home investigate the possibility of installing assistive technology in the bedrooms of some of the service users with a view to enabling the service users control some aspects of their personal environment independently. Meals were varied with the cook having a good knowledge of service users individual needs, likes and dislikes. Food preferences were recorded within the care plans and mealtime advice was provided for staff to enable them to assist service users appropriately. Since the last inspection the home had reviewed and updated its policy that dealt with personal and sexual relationships. Training in this area has yet to be provided for staff but the manager stated that efforts had been made to identify an appropriate course and training provider. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the service users were appropriately addressed. EVIDENCE: The service users care plans contained clear, detailed information as to the personal care needs for each of the service users. The details included the service users preferred routines and the number of staff required to provide support plus any technical aids or equipment. The staff spoken to were aware of these routines and were clearly aware of the service users individual preferences. The healthcare needs of the service user, whose file was examined, were addressed appropriately and there was evidence on service users files to indicate that that a range of health care professionals provided additional support and guidance within the home. A clear record of each of the service users health appointments was maintained to help staff ensure that they had an overview of any health issues. The home had also developed health action plans for each of the service users to enable them to address any health issues in a structured way. One family member stated that the staff ‘were wonderfully supportive and caring’ in a situation when their relative spent a period in hospital. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 15 A number of the health professionals involved in the home also provided training in relation to any specific issues or health conditions that the home managed. The home had worked hard to ensure that any medication was managed correctly. They had developed additional guidance for each of the service users in relation to issues of consent, how medication should best be administered to them and the action to take if medication is refused. The home had also begun to focus on one type of medication each month. Information was made available to the staff team about the medication, its uses and possible side effects. Staff signed to say that they had read the information. The manager felt that this had been a useful method of giving staff information especially as it had prompted staff to ask questions about the medications prescribed to service users. Staff had received training in the administration of medication and the medication policy had recently been updated to reflect best practice. The pharmacist supplying medication to the home also undertook occasional checks on staff administering medication in the home Two recommendations were made in relation to the management of medication. Although in the main the MAR sheets (medication administration records) were completed accurately, the manager should ensure that all staff are following the correct procedure when completing medication records. A record should also be kept when medication is not administered at the home, for example when a service user is visiting relatives. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. The home had good policies and procedures in place to protect service users. EVIDENCE: The policies and procedures in relation to the protection of service users were examined. These contained all the expected information and guidance. The homes training matrix indicated that training had been provided for most staff in the protection of vulnerable adults. A member of staff confirmed that she had had the training. Training in the management of challenging behaviour had been provided and training in physical intervention was planned. Hollydale DS0000006000.V297605.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a clean, well-maintained, comfortable and homely environment for both the service users living at the home and the staff who worked there. EVIDENCE: The home was clean, comfortable, homely and well maintained. Some redecoration was in progress and bedrooms were decorated to reflect the personalities of the service users and their specific interests. Any repairs were attended to as necessary. The laundry within the home was shared with a second home on the same site. It was clean, well – equipped and met the needs of the service users living at the home. The policies and procedures within the home dealing with infection control contained all the expected relevant information and procedures. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff were well trained and positive in their approach, providing good support for the service users. EVIDENCE: The senior and management teams at the home had worked hard to help ensure that the staff team were well motivated and well supported. Senior members of staff were each responsible for a number of support staff. They held meetings with them and passed on any relevant news or information within these meetings. The seniors had received some supervisory training aimed at giving them the skills necessary to support individual members of staff. A member of staff spoken to on the day of the site visit confirmed that these meetings were held. The manager felt that this system was working well and that staff received more individual support as a result of this. The home had also introduced the ‘employee of the month award’ this had been well received by the staff. A notice board within the general office had been designated the ‘positivity board’. The staff team were invited to add to this and photographs of activities carried out in the home, poetry and other contributions had been made to emphasize the positive nature of the work undertaken at Hollydale. Staff were given a variety of training opportunities providing them with the skills necessary provide support to the service users. Many were working towards achieving a nationally recognised qualification in care, although the Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 19 home was still working towards 50 of staff achieving an award. Staff newly appointed to the service received induction training providing them with the necessary basic skills. A training matrix held at the home indicated that the staff team had a good skill mix and all mandatory training had been undertaken. The staff rota at the home had been developed to identify the capacity of staff on duty and those members of staff who had received specific training, helping to ensure that there was always a member of staff on duty with these skills. The recruitment files of two members of staff were examined. These indicated that the home had robust procedures in place, ensuring that the necessary checks and references were undertaken before allowing new staff to commence work at the home. Discussion with a recently appointed member of staff confirmed that the home had a structured and thorough approach to recruitment. The home was aware that its recruitment policy needed to be reviewed and updated and the manager stated that this was being undertaken. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. 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. The manager was well motivated, ran the home well and was keen to improve the support provided for service users wherever possible. EVIDENCE: The registered manager had the relevant qualification and experience to run the home well. She was motivated and enthusiastic in her approach and was keen to ensure that the home met the Care Home Regulations and National Minimum Standards. The manager had undertaken a range of mandatory training and some additional training to keep her skills and knowledge up to date. The home had a range of quality assurance audits in place. It had achieved the Investors in People Award and was working towards the Investors in Care Excellence Award. Both of these awards are quality assurance awards accredited by an external body. There were a number of internal audits in the home undertaken by senior staff to ensure that the home ran smoothly and efficiently and policies and procedures were reviewed as necessary. Regular Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 21 staff meetings helped ensure that quality assurance issues were reviewed and any concerns acted upon. The home had produced a newsletter for families and this had included the results of both a family and a service users survey. The manager took her health and safety responsibilities seriously. Mandatory training within the home was provided for all staff and all equipment and systems were maintained appropriately. Since the last inspection the manager had begun to analyse all accident and incident records so that any pattern or trends could be identified and managed. This had proved to be successful with some strategies having been developed to avoid one recurring incident. The manager must report to the Commission for Social Care Inspection, all incidents that seriously affect the health or wellbeing of the service users. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 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 3 3 2 X 3 X 3 X X 2 X Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA15 Regulation Requirement Timescale for action 30/09/06 18(1)(a)(c)(i) Staff should receive training in sexual and personal relationships. 13(6) The homes recruitment policy and procedures must be reviewed an updated to reflect current best practice. The registered person must inform the Commission for Social Care Inspection all incidents or accidents that seriously affect the health or well being of the service users. 2 YA34 31/08/06 3 YA42 37 31/08/06 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 2 Refer to Standard YA7 YA13 Good Practice Recommendations Service users should be given the opportunity to participate in an advocacy/self advocacy groups. More emphasis should be placed on involving service users in mainstream activities. DS0000006000.V297605.R01.S.doc Version 5.2 Page 24 Hollydale 3 4 5 6 YA16 YA20 YA20 YA32 The home should research the possibility of introducing assistive technology into service users bedrooms. All members of staff should complete medication administration records accurately. A record should be kept when medication is not administered at the home. The home should continue to work towards having 50 of its work force achieve a relevant qualification in care. Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Hollydale DS0000006000.V297605.R01.S.doc Version 5.2 Page 26 - 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!