Inspection on 28/06/07 for Hollydene EMI Rest Home

This inspection was carried out on 28th June 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 but made no statutory requirements on the home.

Other inspections for this house

Hollydene EMI Rest Home 14/05/08

Hollydene EMI Rest Home 31/08/06

Hollydene EMI Rest Home 30/01/06

Hollydene EMI Rest Home 14/07/05

Hollydene EMI Rest Home 16/02/05

Hollydene EMI Rest Home 06/09/04

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

CARE HOMES FOR OLDER PEOPLE Hollydene EMI Rest Home 46 York Road Southport Merseyside PR8 2AY Lead Inspector Mr Paul Kenyon Unannounced Inspection 13:30 28th June 2007 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 Hollydene EMI Rest Home DS0000061914.V332964.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. Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollydene EMI Rest Home Address 46 York Road Southport Merseyside PR8 2AY 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) 01704 534539 Hollydene Care Ltd Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person must at all times appoint a suitably qualified manager that is registered with the CSCI 31st August 2006 Date of last inspection Brief Description of the Service: Hollydene is a residential care home that specialises in the care of older people with dementia. The home is registered to care for up to 25 residents. The home is a large old detached house to which more modern extensions have been added to the side and at the back. There is a large enclosed garden at the rear of the home; the garden to the front has been given over to off road parking. Hollydene provides permanent residential care for its residents. It does not provide nursing care. Hollydene is established in a residential area very close to Birkdale village and railway station. Southport town centre is about 1 mile. There is no registered manager, currently Katherine Diggle manages the service in an Acting capacity, the Registered Provider is Hollydene Care Ltd and the Responsible Person is Mr Tyfun Yilmaz. Fees for the service are currently £389.50 to £415 per week. Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the main key inspection of Hollydene to be held this inspection year (April 2007 to March 2008). The inspection was held over two days and was unannounced. National Minimum standards for older people were used to measure the quality of care provided within the home. The inspection included a tour of the premises, observation of care practice and interviews with staff. Surveys have been made available for relatives to make comments on their experiences. The nature of the disabilities of residents is such that it is not always possible to get a view of their experiences of the care provided to them. As a result, observation of care practice was used to assess the quality of care. The Inspector observed care practice throughout the visits. Staff were noted to work hard and focus their efforts on the care and support of residents. Residents are cared for and are treated in a dignified manner. Staff provide reassurance to residents at all times. What the service does well: Residents benefit from having a plan of care in place, which identified their needs and is reviewed on a regular basis. Residents benefit from having their needs met A safe system of medication is in operation. The privacy and dignity of residents is promoted. Residents benefit from having a programme of activities that they can participate in if they wish and are able to maintain contact with their families. Residents are also able to retain as much independence as possible and have their nutritional needs met. Residents and their relatives have the information they need if they wish to make a complaint and residents are protected from abuse. Residents live in a well-maintained and well-decorated environment. Residents are supported by a well-trained staff team. Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The service still must ensure that the recommendations put into place by the qualified person in relation to the access ramp to the front of the property are put into place. This was a requirement at the last key inspection and has not been addressed. This will enable residents to safely access the building. The service must employ a laundry assistant to ensure that residents can live in a fully hygienic environment and to ensure that residents can be completely supported by the staff team. The service must review its staffing levels to ensure that sufficient care staff are on duty to meet the needs of residents at all times. The service must ensure that the identity of new staff is obtained when they are recruited to enable residents to better protected. The service must forward a candidate to the Commission for Social Care Inspection so that residents can benefit from receiving care from a service that is managed by a permanent and registered individual. The service must ensure that monthly visits by a representative of the organisation occur so that residents can benefit from having their care monitored fully. Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 7 The service must ensure that a restrictor is put into place on the bedroom window identified at the inspection to promote the safety of the occupant. 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. Hollydene EMI Rest Home DS0000061914.V332964.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 Hollydene EMI Rest Home DS0000061914.V332964.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to Hollydene at present Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from having their needs identified before they come to live at Hollydene. EVIDENCE: There have been a number of admissions since last inspection. For the purposes of this inspection, five residents were tracked to assess to what extent their needs had been identified before they came to live at Hollydene. In all cases, residents had been assessed by their Local Authority and copies of their assessments had been received by the home prior to their admission. In addition to this, all residents had been assessed by the home. This home assessment included assessments on a number of needs including health need, care needs, a mental health assessment, a manual handling assessment, Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 10 nutritional assessments, continence assessments, their social history and preferred activities. Hollydene EMI Rest Home DS0000061914.V332964.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from having a plan of care in place, which identifies their needs. Residents health needs are met and they have their privacy and dignity promoted. Medication systems are safe. EVIDENCE: Care plans were examined for the same residents identified in the previous section of this report. In four instances, care plans were available and outlined the care needs of the individuals they related to. One care plan had not been devised yet the home had recognised this and had addressed this by the second part of the inspection. The last inspection noted that the service had started to arrange one to one meetings with family members in order for them to discuss the contents of care plans and verify their agreement with it or otherwise. Evidence was provided that these meetings are continuing. Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 12 The health needs for the same residents were examined. All residents have their medical needs assessed prior to admission and there was evidence that all residents are registered with a General Practitioner. There was evidence of other professionals being involved, for example District Nurses and Community Psychiatric Nurses (CPN) for some individuals. There was evidence of the weight of residents being monitored and continence assessments being in place for all as a matter of routine prior to admission. All medical appointments are recorded and these indicated instances where General Practitioners, District Nurses were contacted, blood pressure checks and ear syringing by professionals and dental appointments. Two individuals have their blood sugars monitored and the responsibility for this is done by care staff following an awareness session given by a District Nurse. All blood sugar levels are monitored. There was evidence for one person of their attendance at a clinic for the monitoring of their use of a particular type of medication. An event occurred during the inspection involving a resident who appeared unsettled. The staff team sought contact with a Community Psychiatric Nurse in order to arrange a review of this person’s needs. Medication is stored in a lockable portable trolley, which is tethered securely when not in use. A monitored dosage system in use and no residents selfadminister although this is considered at admission and risk assessed. There was evidence through certificates that staff who administer medication have been on medication awareness course. Controlled medications are prescribed and these are stored in a separate, locked cupboard and a register is in place, which is appropriately signed after administration. Medication records include records of received medication and all administration records are appropriately signed. In respect of dignity and privacy, preferred names of residents are included in care plans. There was evidence that residents’ clothing is marked discreetly in laundry area and that residents appeared cared for in their appearance. Shared rooms are in use. A requirement at the last inspection was raised about the lack of screening in one room. This room is now singly occupied and was viewed by the Inspector. Other shared rooms have screening in place for their occupants. There was evidence of staff knocking on bedroom doors prior to entering throughout inspection. An event occurred during the inspection involving one resident who appeared agitated and unsettled. Staff continued to talk to her in a reassuring manner and ensured that other people were not unduly upset or disturbed by her actions. Hollydene EMI Rest Home DS0000061914.V332964.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from having their routines respected and are provided with meaningful activities. Residents benefit from community contact and are able to have as much control over their lives that their disability will allow. The nutritional needs of residents are taken into account. EVIDENCE: A number of care plan review meetings continue in order to discuss with relatives the preferred routines of residents and this is ongoing. All residents whose assessment forms were examined at this inspection had had their preferred interests determined. A timetable of activities are in place and provided activities such as television, nail care, hairdressing, arts and crafts,music, quizzes, discussion cards and chair exercises are provided. Activity records are in place confirming these. There was evidence of arts and crafts being done with work on display in the activity lounge and within personal files. One lounge area is used for activities and some staff have been allocated responsibilities to co-ordinate these. A minibus is available to the home. At the last inspection, reference made to an individual who followed a Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 14 particular religion. There was now evidence that steps had been taken to gain more information on this and the implications for this person’s care. There was evidence that preferred routines have been discussed with relatives and that care plan reviews have included the involvement of families. One new admission had been clearly used to accessing the community on her own yet this is now considered as unsafe. Steps have been taken to ensure that this person is able to access the community safely and with staff support. A visitors book and general diary include names of all those who have visited residents as well as the names of those who have been visited. General inspection surveys have been made available to relatives although there has been no reponse at time of report. Any comments will be used as continual assessment of the quality of care provided in the home. There was evidence through a tour of the building that personal effects have been included within residents rooms eg furniture , photographs and other effects. Advocacy literature is available on display in the main hallway. There was evidence of residents being enabled to mobilise independently within the home with staff only intervening to guide residents to particular areas. Menus are available over a three-week basis to suggest that alternatives are in place. A system has been developed whereby residents are able to express their preferred meals and records are kept of these. Drinks were also available during the inspection. Some residents have nutritional needs. One need relates to health with these individuals having diabetes and one is a vegetarian. Nutritional needs are completed as part of the assessment process and there was evidence that these had been reviewed in some cases. A dining area is available and there is space for all individuals. The Inspector observed the provision of lunch during the visit. Most people are able to eat unassisted although some did need assistance with cutting their food. This was done discreetly. Each person was assisted to his or her table and staff ensured that they were comfortable. One person appeared unsettled during the meal time. This upset some other residents and steps were calmy taken by staff to reassure all concerned and in the end the situation was resolved with the individual still being offered a meal. Hollydene EMI Rest Home DS0000061914.V332964.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are given the information they need to make a complaint and where complaints are made there is evidence that these are responded to and investigated. Residents are protected from abuse. EVIDENCE: No complaints have been received by the Commission for Social Care Inspection since the last inspection. A complaints procedure is on display and includes reference to the Commission for Social Care Inspection. Complaints records are maintained with an emphasis on compliments also being retained. Complaints records noted that the last complaint was made in June 2007. This was recorded and investigated. All complaints are divided into complaints, concerns and allegations. Two complaints have been made since the last key inspection. Guidance is in place for senior staff providing information on what to do if an allegation of abuse is made. A Local Authority procedure is also available. A whistle blowing procedure is available with evidence that staff have signed this to acknowledge their understanding of it. Policies are also in place in respect of staff involvement in the financial affairs of residents. restraint and physical/verbal aggression. No allegations of abuse have been made since the last key inspection. Interviews with two members of staff noted that both were Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 16 aware of the whistle blowing procedure and that abuse awareness training had been arranged for later in the month. Hollydene EMI Rest Home DS0000061914.V332964.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a home like and well decorated environment. Residents who have mobility needs do not benefit from ease of access into the building. Residents do not fully benefit from a hygienic home. EVIDENCE: Maintenance staff are employed by the home. A tour of the premises noted that there were no major issues in respect of redecoration throughout the home. Communal areas are available; the home is secure and enables residents to move around in safety. A refurbishment list is available and there was evidence that areas are well decorated. Access to the rear garden is possible. All external areas are secure and no CCTV is in operation. The garden area is currently being developed Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 18 A requirement at last inspection highlighted the need to reassess the premises in respect of aids and adaptations. A further assessment had been done by a qualified person and this identified that the ramped access to the home is unsuitable. This arrangement remains and a requirement is raised once more in this report The tour of the premises noted that no offensive odours were identified. The management of dirty laundry continues to be satisfactory. The laundry has been upgraded and now has a non porous floor and washable walls. The Laundry contains industrial appliances. The home has domestic staff on duty but their role does not cover the washing of laundry. This is part of care staff’s role. It is required that a laundry assistant is employed for reasons of hygiene but also for reasons of ensuring that care staff can attend to their role in supporting resdeints. Protective clothing is available as well as soap and towels in all areas. A clinical waste system is also in place and a sluice separate from toilets and bathrooms is available. Hollydene EMI Rest Home DS0000061914.V332964.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels do not meet the needs of residents. The recruitment process does not fully protect residents. Residents are supported by well-trained staff EVIDENCE: Interviews with two members of staff were held. It was concluded through these interviews and through observation and examination of the staff rota that staffing levels are not adequate. It was noted on the second day of inspection that a Deputy Manager and two care staff were on duty for the first part of the inspection and then a temporary acting Manager came on duty. Although a cook and domestic staff were present, in effect only three staff were able to work with residents. A discussion was held with the registered provider about this and it was agreed that staffing levels were not necessarily meeting the needs of residents at present. This is seen in addition to the absence of laundry staff already identified as a requirement in this record. The last key inspection noted that four care staff were on duty and then three care staff in the afternoon and this has decreased. This was raised as a requirement at the last inspection It is required that staffing levels reflect the needs of residents. Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 20 Three staff files were examined to assess the recruitment of staff. All documentation in place was in place in relation to references and police checks with the exception of proof of identity for one person. This is raised as a requirement in this report. Training provided was determined through interviews with staff. Both confirmed that they had had manual handling training, food hygiene, drug awareness and other mandatory training. Abuse awareness is about to take place later in July 2007. Another member of staff had been on an activity course, dementia awareness training, mandatory training and abuse awareness. Certificates of training were available as well as a training programme. All training is advertised to staff. Mandatory training in place also includes the control of substances hazardous to health (COSHH), medication awareness, confidentiality, food hygiene and fire prevention training. Hollydene EMI Rest Home DS0000061914.V332964.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive care from a service that does not have a manager who has been approved by the commission for social care inspection. Residents do not benefit from a service that fully assesses the quality of the care it provides. The health and safety of residents is not fully promoted. EVIDENCE: An application had been submitted to the Commission for Social Care Inspection for the registration of the Acting Manager this was ongoing until the second part of the inspection where it was noted that the acting manager had left without the registration process being completed. It is required that a new Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 22 candidate is forwarded to the Commission for Social Care Inspection for their registration to be approved. In respect of quality assurance, it is part of legislation that a representative of the organisation visits on a monthly basis and reports on the quality of care provided. These are known as regulation 26 visits. Only three visits have been conducted this year. This is raised as a requirement in this report. A stakeholder survey was completed earlier in 2007 and this included relatives, residents and professionals who deal with the service. All results of this survey have been made available to all those who took part and are on display in the foyer of the home. An external and independent quality assurance process is also used and includes the views of staff with a rating score provided. The Inspector was able to view all records, speak with residents, tour the premises and conduct staff interviews with the co-operation of the management team. A number of health and safety issues were examined: Manual handling training as evidenced staff interviews and the viewing of certificates. Accidents are recorded and an analysis of accidents takes place monthly. Staff have received fire awareness training. Tests are carried out on fire alarms, emergency lighting and fire fighting appliances. Fire drills also take place. Tests have been made to portable electrical appliances, gas appliances and electric wiring in the home. A test on legionella was completed at the last key inspection. The accident analysis that takes place on a monthly basis contains reference to slips/trips and falls, burns and scalds, the reporting of untoward incidents, cuts and bruises and manual handling issues. Radiators are covered in all areas and attention is paid to the security of the building through a number of external doors being locked as well as sidegates. External fire doors are alarmed and minimise residents being at risk if they leave unsupervised. One bedroom does not have a window restrictor. The fitting of this restrictor is raised as a requirement in this report. Hollydene EMI Rest Home DS0000061914.V332964.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 2 STAFFING Standard No Score 27 1 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Hollydene EMI Rest Home DS0000061914.V332964.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 OP22 Regulation 23 Timescale for action The recommendations outlined in 30/09/07 the assessment of premises in relation to aids and adaptations must be implemented Previous requirement not met original timescale 30/06/07 The service must employ a 31/08/07 Laundry assistant to take infection control into account and enable care staff to concentrate on their role The staffing levels during the day 31/08/07 must be reviewed to ensure that sufficient staff are on duty to meet the needs of residents Previous requirement not met original timescale 31/12/06 All personnel files must include 31/08/07 proof of the identity of staff The organisation must forward a 31/08/07 candidate to the Commission for Social Care Inspection to apply for registration as Manager Monthly visits conducted by a 31/07/07 representative of the organisation must be carried out monthly DS0000061914.V332964.R01.S.doc Version 5.2 Page 25 Requirement 2. OP26 13 18 3. OP27 18 4. 5. OP29 OP31 19 8 6. OP33 26 Hollydene EMI Rest Home 7. OP38 13 A restrictor must be fitted to the bedroom window identified during the inspection. 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hollydene EMI Rest Home DS0000061914.V332964.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Hollydene EMI Rest Home DS0000061914.V332964.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!