Inspection on 24/01/08 for Hollyfields

This inspection was carried out on 24th January 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hollyfields 28/02/07

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

CARE HOMES FOR OLDER PEOPLE Hollyfields Habberley Road Habberley Kidderminster Worcestershire DY11 5RJ Lead Inspector Keith Salmon key Unannounced Inspection 24th January 2008 10:00 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 Hollyfields DS0000069242.V356794.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. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollyfields Address Habberley Road Habberley Kidderminster Worcestershire DY11 5RJ 01562 514810 01562 514812 hollyfields@barchester.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) Barchester Healthcare Homes Ltd Mrs Jane Gail Pye Care Home 41 Category(ies) of Dementia (41), Dementia - over 65 years of age registration, with number (41) of places Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2007 Brief Description of the Service: Operated by Barchester Healthcare Limited, Hollyfields is a 41-bedded care home offering nursing care for people with dementia type illness. Situated on the outskirts of Kidderminster the home was purpose built in 1996, and is set in extensive grounds, which it shares with High Habberley House, a separately registered nursing home, also operated by Barchester. Accommodation comprises 31 single and 5 double bedrooms all with en-suite facilities. There is a large lounge, dining room, and dedicated activities room on the ground floor, with an additional lounge situated on the first floor. Access to the first floor is via use of either of the two passenger lifts or the two staircases, with both lifts having sensors to prevent the doors accidentally closing when entering the lift. Outside, Residents have use of a sensory garden and a walled patio area. Fees charged are determined following pre-admission assessment and, therefore, are not stated in published information, such as the Home’s brochure or Service User Guide. Additional charges are made for chiropody (private), hairdressing, and newspapers. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced ‘Key’ Inspection commenced at 10.00am, concluded at 3.30pm, and was conducted by Mr Keith Salmon. Present on behalf of the Home was the Registered Manager, Mrs Jane Pye and Ms Sian Richards, Clinical Development Nurse for Barchester Healthcare, who was visiting the home on the day of the inspection as part of the parent company’s quality assurance programme, e.g. undertaking ‘whole home’ audits and staff training. In addition to an inspection of ‘Key’ Standards, this Inspection also sought to review progress in meeting ‘Requirements’ arising from the most recent Unannounced ‘Key’ Inspection, held in February 2007. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff files and duty rotas, plus a range of other documents/records reflecting the general operation of the home. The Inspector also held individual discussions with 3 Residents, 5 Visitors, the Manager, Barchester Healthcare’s Clinical Development Nurse, and several other members of staff. What the service does well: What has improved since the last inspection? The eight Requirements cited at the previous inspection, which related to shortfalls in the areas of information for residents, care planning documentation, administration of medicines, staff training records, and formal staff supervision arrangements, have all been fully met. A number of new specialist baths have been introduced, and virtually all of the Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 6 furniture in the bedrooms and communal rooms has been replaced, with the remainder on order to be replaced in the weeks following this inspection. In addition, the dining experience of Residents has been enhanced through the introduction of new menus, and improvements to tray presentation for those Residents choosing to take meals in their rooms. There has also been marked improvement in the activities/leisure programme including the purchase of a mini bus. 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. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Residents, and/or their ‘supporters’, are provided with information, which enables them to make a decision as to the home’s ability to meet care needs and lifestyle wishes. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied, and subsequent findings are utilised to ensure appropriate placement and care provision. EVIDENCE: A Requirement from the previous inspection was:The service users guide and if necessary the terms and conditions must be amended in line with recent changes to the regulations. The Home’s information brochure, which incorporates the ‘Service User Guide’ and terms and conditions documentation have been revised and now meet the requirements of the Standard. This Requirement is met. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 9 A review of recently admitted Residents, including the five who were case tracked, showed appropriate and thorough care needs assessment is undertaken by the Manager, or one of three suitably experienced trained nurses, prior to admission. Information gathered is utilised in enabling an informed decision regarding the Home’s capability in meeting the individual care needs of each prospective Resident. All Residents have suitable ‘Terms and Conditions’ contract/documentation. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The content, organisation and quality of entries within care plans, indicate Residents’ individual assessed care needs are fully met. The reception, storage, disposal and record keeping, in respect of medicines’ administration are all in accordance with accepted ‘good practice.’ The care provided is delivered considerately and effectively with Residents’ privacy and dignity being respected. EVIDENCE: Two Requirements were issued at the previous inspection in respect of this ‘outcome group’:“Care plans must contain up to date information regarding all aspects.” “Ensure that records regarding medication and its administration are clear, accurate, and up to date to ensure that residents received items as prescribed.” Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 11 Review of care related documentation demonstrated the Home has completed the process of transferring to the corporate care plan model currently operated by Barchester Healthcare. This model provides very comprehensive coverage of initial assessment/care planning, risk assessment, progress and evaluation. Care plans are well organised with a high level of detail relating to the Residents’ individual needs, together with clear statements of care to be provided. This detail ensures Nurses and Carers are enabled to fully meet those needs in an informed and safe manner, regardless of who is providing direct care at any given time, and the depth of detail included is commendable. Staff maintain a daily record based on one entry per day with the frequency of which is increased as necessary. Evidence was also observed indicating involvement/agreement of Resident or Relatives with care planning proposals – a fact directly confirmed through conversation with visiting Relatives. Regular care needs review is undertaken on a monthly basis, and more frequently if necessary. This Requirement is met. Inspection of medicine storage provision and administration records demonstrated the Home’s practices now fully meet the guidelines of the Royal Pharmaceutical Society. Evidence was also observed demonstrating regular audit through medicine administration practices by the Manager, the company’s Clinical Development Nurse, and by the visiting pharmacist from Boots Pharmacy. This Requirement is met. During our tour of the Home, and in discussion with Residents, relatives/visitors, management and staff it is evident care provided is delivered considerately and effectively with Residents’ privacy and dignity being respected. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A good range of activities is offered, which are consistent with individual Resident’s capabilities and relatives’ expectations. Opportunities for contact with family/friends/community are established and encouraged. The Home provides a daily choice of attractive and nutritious meals based on Residents’ preferences. EVIDENCE: The provision of social/leisure activities, which are especially pertinent to the needs of the client group, is a notable strength. The enthusiasm and knowledgeable leadership by the Manager, who is undertaking the ‘Memory Lane’ training with Barchester and is soon to commence a second stage of a course in ‘Dementia Mapping’ with Bradford University, is commendable, as is the ongoing support from the parent company. The Home has a dedicated ‘activities/crafts’ room, which also provides direct access to the adjacent secure sensory garden. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 13 To assist in ensuring effective application of this development the Home employs a full time Activities Coordinator with whom we held a detailed discussion. Through this discussion, together with perusal of the activities diary, it is clear the Coordinator has a very ‘hands on’ approach, and applies thoughtful, innovative and skilled input into the development and provision of relevant and appropriate leisure/social activities, personalised to Resident’s individual needs and abilities. This wide range of activities include dedicated time spent chatting ‘one to one’ with Residents, with a daily visit to those Residents who choose to remain in their bedrooms, reminiscence activities involving talks about their family history and photographs, accompanying Residents to undertake ‘domestic’ tasks that they may wish to do, such as “a bit of hoovering”, reading letters and assisting in response, garden walks, card games, singing songs, quizzes, poetry reading, jigsaws, arts and crafts sessions, ball games, skittles, hoopla, newspaper reading, accompanying Residents to Holy Communion. The commitment of the Home and the Activities Coordinator to this important area of care is commendable and to be applauded. The Manager operates an ‘open-door’ policy for relatives/visitors, who may wish to discuss their relative’s/friend’s care. Relatives informed us they took advantage of this arrangement, as and when necessary, and all felt they were well informed. All relatives/visitors spoken with were very complimentary regarding the quality of service provided and the caring approach of all staff. It was quite evident to us the routines of daily living are very flexible and based on a ‘person centred’ approach to care provision. The atmosphere of the home is welcoming and visitors are enabled to assist themselves to drinks from the drinks machine provided in the entrance hall. Visitors can, and do, join their relatives for lunch by prior arrangement. In addition, the dining experience of Residents has been enhanced through introduction of new menus and improvements to tray presentation for Residents choosing to take their meals in their rooms. Each day’s menu is displayed in the entrance hall and offers a main meal choice at lunchtime, and a cooked meal or snacks alternative at teatime. Drinks and snacks are available throughout the day. Food is traditionally based and, in the view of Residents and relatives with whom we had discussions, interesting, well presented, and very enjoyable. Specific dietary requirements are met and menus adapted to individual preferences/need. To help ensure all Residents are adequately nourished, in addition to frequent and regular weighing, nursing staff use a specifically designed assessment tool (‘MUST’) to identify those at risk of not achieving that aim. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that Service Users and relatives feel their views are listened to and acted upon. Robust procedures and practices are in place to ensure that individuals are protected from abuse. Residents and relatives/visitors are provided with up-to-date information about adult protection. EVIDENCE: The Home’s Complaints Procedure is displayed within the entrance to the Home, and up-to-date information advising on how to proceed in making a complaint is found in the Service Users’ Guide, a copy of which is made available to new Residents in the Home’s ‘Welcome Pack’. Training records evidenced an ongoing programme of staff training in relation to complaints and the protection of vulnerable people. The home works within the adult protection procedure and whistle blowing procedures (updated by Barchester Healthcare in September 2007) and copies of which are available within the home. Evidence was observed confirming Staff have POVA clearance, and satisfactory CRB checks before commencing employment. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 15 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): 19,20,22 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The overall fabric and decor at Hollyfields is of a very high standard, providing Residents with a safe, well furnished, homely, comfortable place in which to live. The standard of cleanliness in the Home is excellent. EVIDENCE: Tour of the Home evidenced the environment to be of a high standard, well maintained and hazard free. The design of décor and furnishings reflect considerable thought has been given to developing an environment, which addresses the particular needs of the Residents. This is illustrated in the personalisation of each Resident’s Room, e.g. where possible door colour is to Resident’s choice, individually chosen door-knockers, and personal artefacts, including photographs, displayed at the entrance to the room. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 16 Within the rooms there was clear evidence of Residents being encouraged to bring personal items into the Home. At the time of this inspection most of the bedrooms had benefited from new suites of bedroom furniture, including a refrigerator for each room. Furniture to complete the programme for all bedrooms was being delivered on the inspection day. In addition, in accordance with the ‘Memory Lane’ approach being developed within Barchester Homes, the corridors are decorated with old photographs taken within the County between 1900 and 1970, newspaper cuttings, and other memorabilia - including artefacts of daily life during that period. There are also many ‘sensory’ pictures featuring embroidery and other textures, and the high ceiling bays on the first floor are hung with large banners, which carry collage scenes, which we were informed are changed in accordance with the seasons and festivities such as Easter and Christmas. Communal rooms are very spacious and comprise a lounge on each floor, and a ground floor dining room, which looks out over the gardens. The dining room, which has recently been redecorated in colours chosen by Residents, has benefited from new dining room furniture (the covering fabric also being Residents’ choice. The overall quality and appearance of décor, furnishing and carpets throughout the Home provides strong evidence of a well-established and well funded rolling programme of refurbishment and redecoration. It was clear from discussion with the Manager that although funding is centrally provided decisions as to the actual expenditure are driven by local requirement. As mentioned in the ‘daily life/social activities’ outcome group the Home has a secure ’sensory’ garden, developed over the past two years from what was a plain patio area, which includes a range of interesting plants set in borders of different heights, so as to improve ease of access for Residents. In addition, the wall abutting the Home has memorial name plaques for previous Residents of the Home. A further enclosed patio area can be reached via the main lounge. Since the previous Inspection, held in February 2007, the Home has implemented several further improvements – Upgrading of a shower room The creation of a Reception/Training Room Re-carpeting of all bedrooms and re-flooring of a number of the ensuite facilities New curtains and bedspreads in all rooms Installation of a new specialist bath Conversion of a small, shared double room into a large single room, which now incorporates space for a ‘sitting room’ area Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 17 Upgrading of all lighting in the dining room and main corridors The purchase of eight new ‘profiling’ beds and a new hoist Re-painting of the outside of the home Redecoration of the main kitchen with damaged tiles removed and replaced Purchase of a new freezer, dishwasher, and oven Introduction of a fruit drinks machine for Residents’ enjoyment and nutrition Staff areas, including the laundry, are separate from the main body of the home and we were informed the current laundry area, whilst adequate for its purpose, is to be redesigned and refitted in the near future. It is expected the laundry will be out of service for one day only and the laundry in the adjoining Home (High Habberley House) will provide back-up support if necessary. The new laundry will then provide a service to both Homes. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,& 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty and skill-mix were sufficient to meet the assessed care needs of current Residents. There is a committed, effective, and well-supported staff group, with the skills and knowledge to ensure Residents enjoy a quality of life, which meets their individual requirements and aspirations. Recruitment and employment practices are consistent with the safeguarding of Residents. Staff receive training, which enables them to be competent to carry out their role in providing safe care to Residents. EVIDENCE: A review of duty rosters, and discussion with staff confirmed that staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. Staff were observed to carry out their duties in an enthusiastic and professional manner. Staff employment records demonstrated they are subject to a thorough recruitment, selection, and appointment process, including the necessary Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 19 Protection of Vulnerable Adults (POVA) register checks and Criminal Records Bureau (CRB) checks, prior to commencement of employment. A Requirement from the previous inspection was: Training records must be able to evidence that staff have received the required training to equip them with the knowledge to meet residents care needs. Review of staff training records and discussion with staff members provided evidence that all undergo relevant orientation/induction programme followed by appropriate on-going training, including a high proportion having attained relevant National Vocational Qualifications (NVQ). The above Requirement is met. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36, & 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced and well-qualified individual, who possesses sound leadership skills, carries out her responsibilities to the full, and promotes a professional ethos. The Home has a welcoming and inclusive ambience, which encourages and enables the full involvement of relatives and friends. The organisation continues to improve and make progress towards raising the standards in all areas for the benefit of its service users. Service Users are safeguarded by the financial procedures operated in the home. Health, safety, and welfare of service users and staff are promoted fully by safe working systems in place. Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Manager, Mrs. Jane Pye, is a highly suitable person to be managing this service having an extensive background of training and experience in caring for those with mental health needs. Of particular relevance is the ‘Memory Lane’ training with Barchester, and ‘Dementia Mapping (Person Centred Dementia Care)’ with Bradford University. Through conversation with relatives and staff, plus observation of staff practice, there is strong evidence the ethos of the home is open and transparent, with the views of relatives and staff listened to and valued. Staff appeared involved and happy in their work. Quality assurance is evident throughout the service, in both a formal and informal manner, through meetings, surveys involving the views of Residents, Relatives and other bodies. Records were observed of monthly audits, undertaken by the Manager, covering all aspects of care delivery, health and safety and training. These audits are scored and indicate how Hollyfields performs in comparison to other Homes within the Barchester Group. This interaction between the Home and the parent body points to a particular strength of the Organisation, which combines a clear and structured way of overall management, whilst, at the same time, maintaining a ‘hands off’ approach and supporting local managers to effect the development of a service to meet local need. This support takes the form of monthly conference calls led by the Managing Director, regular updates on new information relating to the running of the business and regular meetings between the home’s departmental heads. In addition, internal auditors from Barchester Healthcare, plus external auditors, regularly visit the Home as part of the ‘Regulation 26’ visits, and as part of this process the Clinical Development Nurse undertakes an annual ‘whole home audit’. This involves the home meeting a ‘pass target’ of 75 with Hollyfields achieving an overall score in excess of 90 at the most recent audit. All statutory safety checks are undertaken, and maintenance is ongoing, to ensure safety at Hollyfields. In addition, there is regular input from Barchester Property Services Department to ensure a safe, secure environment for residents, relatives, and staff. A Requirement from the previous inspection under the outcome group was:“Staff must receive formal supervision at least six times per year.” Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 22 A review of staff personal files, and related records, demonstrated Staff are now subject to regular supervision. This Requirement is met. The home does not offer a facility for the keeping of Resident’s personal monies. When small costs for extras are incurred, such as hairdressing or private chiropody, Residents or their families are invoiced accordingly. Observation and review of relevant records provided evidence that Health and Safety Policies/Procedures/Practices are satisfactory, maintenance and servicing of equipment regularly undertaken, and appropriately documented, and all COSHH requirements met. Records are maintained for hot water supply to outlets accessible to Residents. Water temperatures tested during the Inspection were found to be satisfactory. Further to internal checks Barchester employs an external organisation to audit the health and safety of the home annually. During the tour of the Home all areas were found to be clean and pleasant reflecting effective input by the housekeeping team. Hollyfields DS0000069242.V356794.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 1 2 3 4 5 6 Score ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X 4 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 X 3 Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulatio n Requirement Timescale for action 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 Hollyfields DS0000069242.V356794.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Hollyfields DS0000069242.V356794.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. 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