Inspection on 04/02/08 for Hollygrove

This inspection was carried out on 4th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollygrove 16/02/09

Hollygrove 12/10/06

Hollygrove 20/12/05

Hollygrove 01/08/05

Hollygrove 29/03/05

Hollygrove 15/07/04

Hollygrove 08/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Hollygrove 49 Roman Road Salisbury Wiltshire SP2 9BJ Lead Inspector Sally Walker Unannounced Inspection 4 February 2008 09:50 th Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollygrove Address 49 Roman Road Salisbury Wiltshire SP2 9BJ 01722 415578 01722 415578 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) www.turning-point.co.uk Turning Point Limited Ms Deborah Stone Care Home 9 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2) of places Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 7 service users with a Learning Disability at any one time No more than 2 service users with a Learning Disability, over 65 years of age at any one time. 12th October 2006 Date of last inspection Brief Description of the Service: Hollygrove is a purpose-built service, initially opened in 1996, providing care and accommodation for nine people with a learning disability, the majority of whom have a range of personal and communication needs. The home is one of a number of care homes and other social care projects operated by Turning Point, a national organisation, within the Salisbury area. The property is situated in a residential area of the city, a short drive or bus ride from the centre. Car parking is available at the property and in the street. Hollygrove is a two-storey building, with residents bedrooms on both floors. All bedrooms are single, have wash hand basins fitted and are close to toilets and bathrooms. Various aids and adaptations are provided for less mobile residents, including a stair lift. Communal space includes a large kitchen and dining area, a sitting room, and seating areas in the hallway and on the landing. There is also an attractive garden. Staffing levels are three staff during the waking day with one waking night staff and one staff sleeping in. Details of weekly fees can be obtained directly from the home. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place on 4th February 2008 between 9:50am and 5.05pm. Ms Deborah Stone, manager, was present during the inspection. We looked at care plans and daily reports, medication, menus and training. We made a tour of the building. We spoke to two staff and two residents, supported by staff. As part of the inspection process we sent surveys to the home to gain the views of residents, relatives, staff and healthcare professionals. Comments are included in the relevant section of this report. We asked Ms Stone to complete an Annual Quality Assurance Assessment. This was completed in full and returned on time. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Care plans are very detailed in setting out all residents’ current care and support needs. Care plans are regularly reviewed and revised. Residents are encouraged to maintain a good lifestyle both at the home and in the locality. Residents and staff have good relationships which are well established. Residents are encouraged to use their own methods of communication. Different systems are in place to support communication. Residents are supported to make decisions about how they live. Regular contact with families is encouraged. Residents have good access to a range of activities both at the home and in the locality. Consideration is given to providing activities that suit residents changing needs through ageing. Residents enjoy a healthy diet. Nutrition is regularly monitored. Residents have good access to healthcare professionals. All residents have had their risk of developing pressure damage assessed by a learning disabilities nurse from the community team. Staff are confident in activating the safeguarding adults process if allegations of abuse or ill treatment of residents are made. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 6 Staff are well trained. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 5 [Standard 2 was not considered as there have been no new admissions since 2003.] Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from ‘easy read’ contracts and terms and conditions. EVIDENCE: No new residents have been admitted to the home for some time. Residents’ files contained pictorial and large print versions of service users guides and licence agreements. These showed clearly what residents could expect from the service and what was expected of them. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from good care planning and continual assessment. Residents are supported to make decisions about their daily lives. Risk assessment does not restrict residents in their daily lives. EVIDENCE: Care plans were very detailed in describing individual needs and how they were to be met and monitored. All aspects of need were identified including communication, offering choice, healthcare, personal hygiene, managing money, decision making, involvement in domestic chores, likes and dislikes, eating and nutrition, mobility, managing behaviours and preferred daily routines. Care plans were regularly reviewed and updated. Risk assessments related to the care plans. The daily reports showed very little detail given the often complex care needs identified in care plans. We talked about this with staff who told us they had little time to write detailed reports. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 11 Staff use different means of communication with residents. This may be speech, Makaton or photographs. We saw much evidence that staff spent time communicating with residents and promoting choice and decision-making. Residents were included in all public conversations and asked for contributions which they gave. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain their chosen lifestyles and social interests. Residents have good access to the locality. Consideration is given to different activities which residents like to achieve. Residents enjoy a varied healthy diet. EVIDENCE: Some residents attend a local day service for younger adults. Other residents go to a service for older people run by Age Concern. The organisation provides an outreach service with one to one activities for some residents. Residents weekly activity programmes provides for a keyworker day. Residents discuss and plan what they want to do. This may involve shopping, going to the theatre or out to lunch at a pub. Residents have an activity board in their bedroom showing what they were involved in each week. Residents had a Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 13 wide range of interests. Staff were aware of some residents tiredness as they got older. Some residents could not necessarily sustain too many activities in one day without rest periods. Ms Stone was considering activities to be provided now that some residents were getting older. Residents routines were more relaxed at the weekends when they did not have to get up as early to go to day services. The home has its own mini bus for residents to access the locality. Ms Stone told us she planned to lease a laptop for residents to use. Residents are encouraged to maintain good links with families. Staff may support residents to write to family. Photographs may be enclosed so that families know what residents have been doing. Ms Stone told us that the menus were compiled to ensure that a healthy diet was given. The three-week menu reflected this with a good range of healthy meals. Any special diets were identified. We saw different ingredients in the fridge and dry stores to meet different diets. This included low fat and full fat yoghurts. Residents have a packed lunch to take with them when they go to day services. They choose the ingredients for their lunch. We saw residents having scrambled egg and fruit for lunch. We also saw an evening meal of cauliflower cheese and bacon which looked appetising. Staff ate with residents. There were also a range of snacks, puddings and ‘treats’ in the stores. There was a large bowl of fresh fruit in the kitchen for residents to help themselves. Comments from relatives survey forms included: “Hollygrove always makes us feel welcome when we visit.” “[The resident] seems very happy at Hollygrove with fewer tantrums/upsets. [The resident] likes to ring me but rarely says much so not sure staff think it’s worth doing.” “We think Hollygrove is a good care home and our [relative] is looked after pretty well as far as it goes. Our anxiety is about Old Sarum training centre which [they] used to attend 4 days a week but they seem to be having several days out now. Hollygrove staff are always busy. They take [the resident] out as much as possible.” [Live the life they choose?] “I don’t think my [relative] is capable of choosing. Considering the nature of my [relative’s] disability I would say that Hollygrove do a fantastic job in looking after [the resident] and including [them] in various activities and trips.” “They make my [relative] welcome and feel part of a family.” “Take an interest in residents families. Also fed well, kept clean dressed well.” Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from very supportive staff. Healthcare needs are well met. Protocols for administration of medication have addressed issues with medication errors in the past. A safe system is now in place. EVIDENCE: Care plans set out how residents wished to be supported with personal care. Healthcare needs were identified. Records were kept of all healthcare interventions and reviews. Residents were regularly weighed. Specialised feeding techniques were recorded following advice from the specialist nurse. There was also clear guidance on giving medication to the resident via the specialised equipment. The GP, dietician and district nurse had been involved in training and supporting staff with specialised feeding techniques. A nurse from the community team for people with learning disabilities had assessed every residents’ risk of developing pressure damage. The nurse had given advice on any risks identified and guidance was available in care plans. Pressure relieving equipment was in place where indicated. Nutritional risk Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 15 assessments were in place. There was clear guidance in care plans about supporting residents with a good diet. Residents had also has a continuing healthcare assessment. Ms Stone said she had carried out investigations into the four medication errors that occurred last year. She had put new procedures in place to reduce the risks. All staff had signed up to the new protocols. They had also all attended accredited medication training at Salisbury College. No further errors have been reported to us. One of the senior staff had the delegated responsibility for medication. All medication is checked against the records as it is received into the home. Administration records were being satisfactorily completed. We advised that handwritten entries on the medication administration record should be witnessed, signed and dated by two staff. Data sheets supplied with medication were kept for staff reference. Homely remedies were only given following advice from the residents’ GPs. We advised that some medication with specific administration guidelines must be included in the care plan. Action had been taken to address the requirement we made that there must be a care plan in respect of any medication prescribed to be taken when required or when self-administered. There was clear guidance in care plans about what prompts an administration of medication that was prescribed only to be taken when required. Comments in relatives survey forms included: “[The resident] is taken to the dentist regular and has [their] hair cut over the years.” Comments in healthcare professionals surveys included: “The health of individuals are observed monitored advice sought from appropriate services when necessary. Health care need are endeavoured to be met through appropriate training when it is acknowledged further advice help sought from primary health team. Staff acknowledge any skills deficits ask appropriate agencies for training relevant to their need. They advocate well for their individual residents, foster a homely atmosphere attempt wherever possible to give each resident choice. [Could improve?] By keeping their knowledge practice up to date by receiving regular training such as administration of emergency medication.” In survey forms two GPs identified positive working relationships with the home. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place for residents and their relatives to make complaints about the service. Staff are confident in using the safeguarding adults procedure. Residents are not protected by the organisation’s policies on residents finances. EVIDENCE: The home works to the organisation’s complaints procedure which was only available in written format. There was a log for recording any concerns and complaint investigations. None had been received. Residents are encouraged to discuss any issues in their keyworker time or with other staff as they wished. Pictorial information and photographs are made available to residents at meetings so that they can raise issues. A local advocacy service is available. It was clear from discussion with staff that they were confident about reporting any allegations of abuse or ill treatment of residents. Residents have their own bank accounts which were kept at the local office. Ms Stone said that she and her line manager were appointees. All residents monies were managed by the local office. Residents had their own money and if they needed any more, the home’s petty cash account was used. Transactions were recorded on individual files. Receipts and details of all Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 17 spending were kept at the local office. Ms Stone checked the records every week. We found that some residents were paying for staff meals when they went out. Further investigation showed that this was mainly when they went out with an outreach worker. Many of the residents do not necessarily have the capacity to make decisions about offering to pay for staff meals. There were no records of any agreement of this kind with either residents, their families or care managers. The service users guides made no mention of paying for staff meals under the heading “you will have to pay for”. However there was some indication that this was Turning Point’s policy. We advised that this practice must stop. We are taking this up with the organisation. Two GPs, in responses to survey forms said they had not received any complaints about the home. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Efforts have been made to improve the environment for residents. The kitchen is long over due for refurbishment and currently poses a risk to residents and staff. High standards of hygiene are in place. EVIDENCE: Residents bedrooms were personalised, comfortable, clean and airy. Residents had purchased their own furniture. Residents could have a key to their bedroom if they wished. Care plans stated whether residents were able to use a key to their bedrooms. No action had been taken to address the requirement we made that the kitchen must be professionally assessed for functionality and made good to modern standards. We asked for an action plan. This has been outstanding for more than a year. Ms Stone reported that the home had been going Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 19 through a change in ownership of the building. The process had taken eighteen months to be resolved. As a result the organisation had to commence new discussion with the new housing association for completion of the works. Ms Stone told us that work was due to start in January but tenders were still awaited. As time goes on the kitchen continues to deteriorate. Many of the doors to the kitchen cabinets and fronts to drawers had come off. Staff were vigilant to the hazards this potentially caused. Ms Stone said that she would be in a better position towards the end of March to let us know how far forward the organisation was in their discussions with the housing association for installation of a new kitchen. Action had been taken to meet the good practice recommendation we made that a plan of redecoration is made of the premises. Staff had made good progress in redecorating some of the residents bedrooms. The sitting room was the next project with residents and parents having decided on the colour scheme. Action had been taken to meet the good practice recommendation that a regular audit is made of areas at risk with regard to infection control. We noted that all areas of the home were cleaned to a good standard. No unpleasant odours were detected at any time during the visit. We noted that a bath surround in one of the bathrooms needed replacing. This is to ensure that the area is sealed and does not present difficulties with cleaning. One of the bathrooms had been upgraded with a specialist bath. Residents are involved in some light domestic tasks. They may bring laundry to be completed by staff. Systems were in place for safe disposal of clinical waste. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a highly committed staff group who are well trained and competent. A robust recruitment process is in place. Staffing levels must be kept under review as current residents age and their needs become more complex. EVIDENCE: The home was nearly fully staffed with only one full time vacancy being recruited. The staffing rota provided for three staff during the waking day. At night there is one waking night staff and one staff sleeping in. We talked with staff about their work given that they had told us that they had little time for detailed report writing. They told us about the different tasks they had to do, for example picking residents up from three different day services, cooking and laundry. They said their priorities were meeting the care and support needs of residents, some of whose needs were complex due to their ageing. We saw that staff did indeed spend quality time engaged with Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 21 residents for personal care and one to one discussions, support and activity provision. We advised that staffing levels must be kept under review to ensure that as residents age their needs can continue to be met. One of the staff told us that they had recently undertaken training in supporting people with learning difficulties who may be dying. One of the senior staff said they had recently completed NVQ Level 3 and were awaiting their certificate. Staff told us that they received regular updated training in moving and handling, medication, Makaton, fire safety, first aid and infection control. Two staff had undertaken training in dementia care at the local college. Ms Stone keeps a matrix of core training subjects which staff are expected to undertake in their first six months of employment. Staff then receive regular updated training. Planned training included: safeguarding adults and abuse, the Mental Capacity Act 2005 and managing behaviours. Ten staff had NVQ Level 3 and two had Level 2. Separate records were kept of staff’s training certificates. One staff, although not newly appointed, told us they had received a good induction into their role. Regular staff meetings are held and staff had supervision every 6 weeks. Staff agreed agendas for meetings and supervision. Staff recruitment records are kept at the local office in agreement with our Provider Relationship Manager. These files are subject to our scrutiny from time to time. Ms Stone said that she is involved in the recruitment process and would be sent copies of relevant documents required in the process. She is also notified when new staff’s Criminal Records Bureau certificates allow them to commence duties. Staff were seen to engage with residents and it was clear that good relationships were established. Comments in relatives survey forms included: “Not sure they all do BUT some staff seem to have the skill/experience required. [Does well?] The care home shows empathy with residents/family. Encourages residents to be the best they can.” “They get short of staff like every where else.” Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from having a manager who is committed to developing the service. The home is run in the best interests of the residents. Residents and staff’s health and safety is continually monitored and well managed. EVIDENCE: Ms Stone had returned to the home after a six-month period of secondment to another service within the organisation. She has the Registered Managers Award. Ms Stone trained as a Psychiatric Nurse. From our discussions it was clear that Ms Stone is clear about how she wished the home to develop. She is understanding of residents changing needs as they begin to age and develop Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 23 more complex needs. She is keen for residents to remain at the home as long as their needs can be met. No action had been taken to address the requirement we made that monthlyunannounced visits are made to the home under regulation 26. The last report from the organisation on the conduct of the home was dated 14th March 2007. The organisation carries out the internal quality reviews of the service. They send questionnaires to relatives and others involved with the service. Responses are sent to Ms Stone for inclusion in her own quality monitoring system. Regular residents meetings were held with photographs to aid residents to decide their agenda. Action had been taken to meet the good practice recommendation we made that the provider should assist the home in drawing up a new fire risk assessment. The fire risk assessment had been contracted out and the results identified in an action plan. Individual care plans identified how residents may respond to a fire situation and how they were to be supported in an evacuation of the building. Individual risk assessments with residents were found in their care plans. Risk assessments of the building and any tasks which residents or staff may be involved in were on file and regularly reviewed. The home worked to the organisation’s policies and procedures which had just been reviewed and revised. Ms Stone produced more local policies which were specific to the home. Staff signed up to the policies and procedures. We found that there was no policy on residents choice about intimate personal care provision by staff of a different gender. Ms Stone said that previously a policy had been in place and she would re-consider developing the home’s own policy pending one from the organisation. Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 N/A 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Hollygrove DS0000028451.V349709.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 (2)(b) Requirement The kitchen must be professionally assessed for functionality, and made good to modern standards. A plan for upgrade to be in place by date shown. (Given that discussion is underway with the new owners of the building, we must be informed of when this work is due to start.) The registered provider must ensure unannounced visits are made monthly in accordance with the regulation. The person registered must ensure that staff report on their interventions with residents as provided by their care plans. The registered provider must ensure that staffing levels are kept under review to ensure that residents changing needs are met. The registered provider must ensure that policies and procedures do not allow residents to pay for staff meals when they cannot necessarily DS0000028451.V349709.R01.S.doc Timescale for action 31/03/08 2. YA38 26 (2) 04/02/08 3 YA41 17 04/02/08 4 YA33 18(1(a) 04/02/08 5 YA23 13(6) 04/02/08 Hollygrove Version 5.2 Page 26 decide to offer to pay. 6 YA24 23(2)(b) The registered provider must 30/04/08 ensure that the bath panel to one of the baths is replaced so that it is easier to keep clean and prevent surface water from running under the bath. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations Care plans should identify administration guidance on medication that is prescribed with specific instructions. 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