Inspection on 28/02/07 for Hollyfields

This inspection was carried out on 28th February 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

Hollyfields 24/01/08

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 Andrew Spearing-Brown Key Unannounced Inspection 28th February 2007 11:30 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.V331798.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.V331798.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 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.V331798.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Hollyfields is a 41-bedded care home offering nursing care for people with a dementia type illness. The home was purpose built in 1996 and is set back from the road in grounds with another separately registered nursing home. The home is on the outskirts of Kidderminster. Residents accommodation comprises of 31 single and 5 double bedrooms. Access to the first floor is gained through either two staircases or two passenger lifts. There is a large lounge on the ground floor as well as the dining room and a dedicated activities room. Another lounge is situated on the first floor. Residents are able to access a sensory garden and a walled patio area. The registered owner is Barchester Healthcare Limited. The registered manager is Mrs Jane Pye who is a Registered Mental Nurse with a degree in mental health. The currently weekly charge is £600 - £950 per week. Additional charges are made for chiropody (private), hairdressing and newspapers. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of any inspection carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at Hollyfields a total of two visits to the home were undertaken. Both of the visits were unannounced. The last statutory visit to the home, which was also unannounced, took place during January 2006. At the time of this inspection the home had 4 vacancies. This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. Prior to the visits a pre inspection questionnaire was posted to the manager requesting certain information. The information was returned to the commission before the inspection. In addition to the pre-inspection questionnaire a number of questionnaires were also sent to the home for residents, relatives and other persons to complete. A total of 5 residents questionnaires were returned to the CSCI prior to the inspection. In addition seven comment cards were returned from relatives / visitors. Four comment cards were received from General Practitioners and two from other health and social care professionals. The findings from the questionnaires are included within this report. A partial look around the home took place concentrating primarily on communal areas and facilities. The care documents of a sample number of residents were viewed including care plans, daily notes, risk assessments and some accident records. Other documents seen included medication records, some service records and some staffing records. In addition to the persons mentioned above discussions took place with a number of trained nurses, some carers and the administrator. Discussions took place with a number of residents throughout the inspection. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The information included within the service users guide needs to be reviewed and amended in line with recent changes in the regulations. Training records need to be able to evidence the training which has taken place. Where gaps in training are identified these need to be addressed to ensure that staff are suitably trained to meet the care needs of residents. Care plans need to include details of all area of residents care needs to ensure that carers are able to meet needs in a consist manner. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 7 The management and administering of medication needs to be improved to ensure the health safety and well being of residents. 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.V331798.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 Hollyfields DS0000069242.V331798.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): Standards 1, 3 and 4. Standard 6 is not applicable. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The documentation supplied to residents and or their representatives regarding fees and the nursing contribution needs to be updated in line with recent changes in the regulations. An assessment of care needs is carried out prior to admission in to the care home to ensure that care needs can be met. EVIDENCE: Neither the statement of purpose or the service users guide was viewed in great detail as part of this inspection. The date of issue of the current versions predated the changes to the Care Homes Regulations, which came into force on 1st September 2006; therefore it is likely that amendments are necessary. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 10 The pre admission assessment of a recently admitted resident contained sufficient information for a care plan to be generated. Hollyfields is registered to care for up to forty-one persons who may have a dementia type illness both under and over the age of 65 years. A number of Barchester care homes, including Hollyfields, have memory lane communities offering ‘ dedicated dementia care.’ The care of persons with a dementia type illness is specialised therefore making it necessary for staff to received suitable training in order that care needs can be met. A number of staff informed the inspector that they had received training towards the end of 2006. The registered manager confirmed that 10 persons attended this training, which was lead by a recognised trainer and expert in the care of persons with dementia. Other staff have reportedly viewed a video as well as taken part in some ad hoc training sessions. Hollyfields does not provide intermediate care and has no plans to provide such a service in the foreseeable future. Hollyfields DS0000069242.V331798.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans need to be up to date and consistent with other information held to ensure that care needs are identified and met. The management of medication needs to be improved to ensure that the systems in place are safe. EVIDENCE: Questionnaire issued by the commission and distributed by the care home to G.P’s were returned by 4 practices. No concerns were noted upon other cards returned. It was noted from the pre-inspection questionnaire that the vast majority of residents are registered with one GP practice. Questionnaires were returned from 2 Health and Social Care professionals who have contact with the home. The comments included upon the questionnaires were positive including ‘ overall I am very satisfied with the care provided.’ ‘The care is of a high standard.’ Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 12 Care plans seen and associated risk assessments were generally in good order. Due to the decanting of papers ready for filing the process of reviewing documents was at times difficult and involved having to search for the required papers. Staff were seen filling out daily records and care plans throughout this inspection. Staff were working towards having one style of care plan in place rather than different. Although care plans were in place for conditions such as chest infections they were not in place to guide staff upon the use of creams and ointments. The registered manager stated that most beds were replaced over recent months. A number of residents had pressure sores and were nursed on either a pressure relieving or pressure prevention mattress. A discussion took place with the manager regarding the need to ensure that advice is sought from a tissue viability nurse for residents with more complex care needs. Risk assessments and records of regular checks regarding the use of bed rails were in place. Staff consulted generally had a good knowledge of the care needs of residents although some inconsistency was noted. The management and administration of medication was assessed as part of this visit. A number of serious concerns were noted and as a result an immediate requirement notice was issued which was followed up by means of a letter detailing the concerns as follows: a) A number of gaps were noted whereby nursing staff had failed to sign for medication administered or to enter a code if omitted. b) It was noted that two staff had signed for different drugs prescribed to one resident for the same drugs round c) Medication was not always booked into the care home d) Information on care plans did not always match information on the MAR sheets e) It was evident that a patch was not always applied as directed Concerns were also expressed to the manager regarding creams found within a bedroom with the labels removed. Care plans and other documentation failed to support reported regimes regarding the application of creams as well as the patch detailed above. A capsule was found on a bedroom locker, this was of concern as it was clear that staff had failed to ensure that medication was taken. In addition the bedroom concerned was unlocked therefore the capsule could have been found by another resident and taken. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 13 As a result of the concerns raised during this inspection the registered manager carried out a full and detailed audit of medication within the home (although medication audits did already form part of the ongoing quality assurance systems within the home) and mirrored the results already uncovered. Following the internal audit and as well as the manager’s audit a letter highlighting the seriousness of the shortfalls was issued to nursing staff. Although the action taken by the registered manager does not detract from the seriousness of the shortfall it does show that an immediate response detailing appropriate action took place once these concerns were brought to the attention of the manager and provider. The registered persons must ensure that suitable and sufficient systems are in place to ensure that similar shortfalls do not happen. A small number of residents have a telephone fitted within their own bedroom. Residents consulted were complimentary regarding the staff at the home. The inspector had no concerns regarding the up holding of residents privacy and dignity throughout the visits. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 14 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): Standards 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. Activities are provided to stimulate residents where possible to enhance quality of life. Meals served are well presented and nutritious to provide a well balanced diet. EVIDENCE: One visitor consulted confirmed that she is able to visit at any time and able to see her relative within the lounge area. Information was displayed for residents and their representatives regarding future activities to be provided this included a visit by an accordion player and Holy Communion. Daily activities listed included art and craft and exercise games. An activities coordinator is employed 5 days per week who is able to use a specific activities room. During this inspection a number of activities were taking place within this room. The inspector was informed that the activities room, which contained a range of games and craft materials, was an Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 15 improvement on the facilities previously available. A sensor garden is reached via the activities room. Some comments received during this inspection indicated that other carers find it difficult to allocate time to spend with residents outside of carrying out personal care tasks. The days menu is displayed in the entrance hall where residents relatives can view it. On the first day of this inspection it was noted that the main mid day meal consisted of a choice between roast beef with Yorkshire pudding or turkey casserole with potatoes, cauliflower and sprouts. For pudding the menu stated ‘selection of desserts from trolley.’ The meal seen was well presented and appeared appetising, residents consulted spoke highly of the meals provided. Staff were seen assisting residents appropriately within the dining room. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a suitable complaints procedure in place. Recorded evidence of staff training regarding the protection of vulnerable adults needs improving however staff had knowledge which assists in the safeguarding of residents. EVIDENCE: The commission has recently received an anonymous complaint regarding some aspects of care provided within the care home. Issues within the complaint have being passed to a representative of the registered providers. Five out of seven relatives who returned a questionnaire to the commission prior to this inspection stated that they were aware of the home’s complaints procedure. Five questionnaires were returned to the commission completed on behalf of residents. A total of three residents stated that they did not know how to make a complaint while one stated sometimes and one stated always. The complaints procedure is included with the homes service users guide, statement of purpose and the welcome booklet. The registered manager stated that the home had not received any complaints since the last inspection. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 17 A number of letters / cards complementing the service were displayed. A copy of a recently issued booklet upon the safeguarding of vulnerable adults issued by the local authority was displayed in the office. The registered manager had copies of policies and procedures including the Worcestershire guidelines. Safeguarding / protection of vulnerable adults is included within induction training. Despite the apparent shortfall in training provided (or recorded if training has occurred) staff consulted were able to demonstrate a satisfactory understanding of their individual responsibilities under the local safeguarding of vulnerable adult procedures. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 18 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): Standards 19, 20, 21, 23, 24 and 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Improvements to the standard of the environment continue in order to provide residents with a comfortable place to reside where care needs can be met. EVIDENCE: Hollyfields was built about 10 years ago in the grounds of another and separately registered nursing home. Barchester Healthcare Limited took over the management of the home about 5 years ago. The previous inspection report stated that the home offers a high standard of accommodation to residents. Access beyond the front reception area is via a door with a coded keypad. The dining room, which was set out pleasantly for lunch, looks out to the front of the home. It was reported that new furniture Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 19 for the dining room is on order. The décor on the dining room wall is interesting and could instigate conversations between residents and or with staff. Lighting within the dining room and the lounges was domestic in style and suitable. A lounge area is located on both the ground and first floor. Both lounges are spacious and well furnished. The décor along corridor areas was generally in good order. The registered manager reported that all bedrooms have been re-carpeted over the last 18 months and all had new curtains over the past 12 months. A former double bedroom, which was to be used as a premier single, was attractive in appearance. Full privacy curtains are in place within double bedrooms. The home is registered to care for persons with a dementia type illness. Many of the features on the walls (pictures taken within the County between 1900 and 1960’s, newspaper cutting and other memorabilia) and on the top floor items hanging from the skylight are suitable for people with dementia and the home should be commended for having good insight regarding the care of persons with a dementia type illness. Facilities within communal areas including a rummage area are also suitable. The majority of residents bedroom doors had pictures or photographs upon them to assist resident recognise their own room. It was evident that residents or their representatives had individualised bedrooms with personal belongings. Residents are able to access the first floor by means of two passenger lifts; both lifts have sensors fitted to prevent the doors accidentally closing upon a person entering the lift. The registered manager stated that all windows above ground floor level have restrictors fitted to prevent intentional or accidental falling. Privacy locks were fitted to all but one of the communal toilets and bathrooms doors checked. It was reported that an Environmental Health Officer from the local district Council visited the care home during February 2007 and that the shortfalls identified had been addressed. The grounds were well maintained for the time of year. A sensory garden can be reached via the activities room. The registered manager has instigated the displaying of name plaques of former residents on the wall within the sensor garden area. A small-enclosed patio area can be reached via the main lounge. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 20 Staff areas including the laundry are separate from the main body of the home. The laundry area was suitable for its purpose and in line with the associated national minimum standard. Feedback upon the questionnaires completed on behalf of residents regarding whether the home is fresh and clean was mixed. Disposable gloves and antibacterial soap was available for staff to use Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Suitable recruitment procedures were in place which can assist in the safeguarding of residents. A review of staffing levels needs to take place to ensure that care needs including social and recreational can be met. The number of qualified carers employed within the home is above the required standard. EVIDENCE: On the day of the first visit of this inspection 6 carers were on duty in addition to 2 trained nurse and the registered manager who is also a trained nurse who specialised in mental health. Other staff working within the home included an activities coordinator, a cook, a kitchen domestic, a housekeeper, a domestic and a maintenance person. Rotas seen evidenced that it is usual to have two trained nurses on during the morning shift (not including the registered manager) and one at all other times. The activities organiser works between Monday and Friday each week. The afternoon staff consists of one less carer. 1 nurse and 3 carers cover the night shift. Comments included earlier within Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 22 this report indicate that staff believed they sometimes had insufficient time to meet care needs other than personal care. The documents held relating to a recently appointed employee were looked at. This file evidenced areas of good practice in relation to recruitment such as the obtaining of both a PoVA (Protection of Vulnerable Adults) first check and an enhanced CRB (Criminal Records Bureau) disclosure), prior to the employee commencing their first shift within the home. The training records of a number of members of staff were viewed. The registered manager stated that the company are shortly introducing a new method of capturing information regarding training undertaken which will also flag up when refresher training is due. Currently a number of different systems of recording are in place making it difficult to assess the overall training provided. The records showed some gaps in relation to moving and handling, infection control, safeguarding / protection of vulnerable adults, first aid and fire awareness. It was stated that out of 20 carers 11 currently hold either a level 2 or level 3 National Vocational Qualification, this would account for 55 of the current care staff. This level is therefore just over the required level of 50 qualified carers. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The registered manager is a trained nurse and has extensive experience. Quality systems are in place but did not pick up the shortfalls identified regarding medication. EVIDENCE: The registered manager is a registered nurse. A certificate on display evidences that she obtained the Registered Managers Award level 4 NVQ (National Vocational Qualification) during March 2006. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 24 An internal audit was taking place within the home on the morning of the first visit. The inspector is not aware of any concern generated as a result of this routine audit by the company. The company have in place a range of quality audit systems, which are used over the course of a year. The audits used include ones relating to the medication system however as reported earlier within this report a range of serious concerns were identified as part of this inspection. In addition to audits carried out internally a representative from the company visits the home regularly and prepares a written report upon the conduct of the home. It was reported that the company recently issued some questionnaires to residents representatives; once the results are collated the findings should be available to current and prospective residents as well as other interested persons including the commission. The home does not offer a facility for the keeping of residents cash: residents or their families are invoiced for extras such as hairdressing or private chiropody. The registered manager accepted that formal supervision as detailed within the national minimum standards had not taken place in the past however measures to rectify this shortfall were in place. During the first visit of this inspection some concern was raised regarding reports received regarding the servicing of lifting and hoisting equipment. The registered manager was able to demonstrate as part of the second visit that all hoisting equipment was re-serviced to ensure safety. Training in relation to some health and safety matters is included within the comments made earlier within this report. Some items were found which had missed regular portable electrical appliance checks including an overhead hairdryer, which showed it needed to be checked March 2003 (therefore almost 4 years out of date). Fire records were viewed and showed that monthly checks had taken place. A revised Fire Risk Assessment dated December 2006 was seen but not read in full as part of this inspection. Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 25 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 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 2 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 5A 5B Requirement The service users guide and if necessary the terms and conditions must be amended in line with recent changes to the regulations. Care plans must contain up to date information regarding all aspects of residents care. Timescale for action 30/06/07 2 OP7 15 31/03/07 3 OP9 13 (1) Ensure that records regarding 28/02/07 medication and its administration are clear, accurate and up to date to ensure that residents received items as prescribed. 4 OP30 OP4 OP18 OP38 18 (1) 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. 30/04/07 Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 27 5 OP36 18 Staff must receive formal supervision at least six times a year. Previous timescale of 31/01/06 not met. New timescale given. 30/06/07 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 Hollyfields DS0000069242.V331798.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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.V331798.R01.S.doc Version 5.2 Page 29 - 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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