Inspection on 12/02/07 for Hollystead

This inspection was carried out on 12th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollystead 13/02/09

Hollystead 28/01/06

Hollystead 26/11/05

Hollystead 10/02/05

Hollystead 12/08/04

Hollystead 28/07/03

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Hollystead 14 Old Mill Lane Liverpool Merseyside L15 8LN Lead Inspector Lesley Owen Unannounced Inspection 12 February 2007 11:00 th Hollystead DS0000025350.V320702.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 Hollystead DS0000025350.V320702.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. Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollystead Address 14 Old Mill Lane Liverpool Merseyside L15 8LN 0151 722 7874 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) Nugent Care Ms Bridget Lacey Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Sixteen (16) LD (PC) and Five (5) PD (PC) within an overall total of 16 One (1) named SI person within the overall number of 16 One (1) named LD/E person within the overall number of 16 LD Date of last inspection 28th January 2006 Brief Description of the Service: Hollystead is a spacious Victorian house situated in the Liverpool 15 area of the city. It is set in its own extensive grounds and has off road parking facilities. The original building has been adapted to ensure that the facilities of the house and garden area are accessible and available to all service users. A unit has been added on the ground floor, which is ramped in order to give easy access to the main part of the house. Accommodation consists of: on the ground floor two lounges, central dining room and kitchen, in the basement there is a quiet room, an activities room and a light and sound room has been created which is nearly complete. There are sixteen single bedrooms, which are furnished to a high standard, and all have wash hand basins. The home currently has four bathrooms for use by service users that includes assisted bathing facilities. The house is centrally heated throughout. Hollystead was registered in November 2000 as a residential care home to provide permanent and respite care for a total of 16 adults with severe disabilities, some of whom also have physical disabilities. Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit began at 11am and took place over seven and half hours. The manager was on duty at the time. At the start of the inspection there were 4 residents at home and the other residents were at day services. The inspector spoke with manager, three team leaders, support and agency staff and residents during the time at the home. During the inspection time was also spent in the office examining records held for residents and staff, a sample of maintenance records were also seen and a tour of the house was made. In addition the manager completed a preinspection questionnaire which provided the inspector with additional information and a number of survey forms were sent out to resident’s relatives. What the service does well: What has improved since the last inspection? Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 6 Over half the care staff have achieved a recognised qualification in care and further staff are currently completing a National Vocational Qualification (NVQ). The new care planning format that was introduced at the time of the last inspection continues to be developed to provide residents with a service more tailored to their individual need, interests and abilities. 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. Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 7 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 Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 8 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): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to being admitted to the home the needs of the prospective resident would be assessed to ensure that their identified needs can be met. EVIDENCE: Detailed written information and a video have been produced about Hollystead and the service that the home provides, so that prospective residents and their families are able to get information and see if the home is right for them before moving in. All service users whether referred for respite care or for a permanent place at Hollystead are assessed prior to admission. One new service user had been admitted to the home since the last inspection and the inspector was able to view both the care management assessment and the assessments undertaken by the home. When the home received the referral for placement the manager arranged to visit the prospective service user and their family and to attend planned reviews to be held by the placing Authority. Prior to coming to Hollystead prospective residents and their family are invited to visit the home at various times and this can include having a meal and overnight stays prior to coming to live at the home. This procedure was followed for the last resident to be admitted to the home. Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 9 The current scale of charges at Hollystead are from £824.84-£842.66 per week and additional charges are made for hairdressing, activities in the community, holidays, transport, some toiletries and chiropody. Hollystead DS0000025350.V320702.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning continues to be developed in the home to ensure the individual needs of the residents are met. Risk assessments were in place to support work with the residents. EVIDENCE: At the time of the last inspection person centred planning was being introduced for use in the home. The new plans are called “About me” and when completed provide detailed information about the person covering many areas of their life from what they like doing to what they would like to achieve. These plans can include photographs of special people or events and information can be added as circumstances in the residents life change. The staff have continued to work with residents and their family and other people involved in their care to make these documents comprehensive and work is on going. In addition each residents has a care plan that describes their needs and how they are met. These plans are reviewed regularly so that any changes to the way people need to be cared for are recorded. Formal reviews are held every six months where everybody involved in the care of the resident is invited. A record of Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 11 daily record of events is completed by staff for each resident including checks and support given to residents during the night. Risk assessments are carried out for both personal and environmental risks and action taken to minimise identified risks and strategies are put into place to assist the resident to develop and improve their skills. Both the manager, team leaders and support workers on duty at the time of this visit demonstrated that they had a good knowledge of the individual residents needs and how these are communicated despite the a number of residents having little verbal communication. Good relationships were observed to have been developed between residents and staff and between residents. The organisation have a policy and procedures about maintaining confidentiality and record keeping and this is covered during the induction training for new staff to ensure all information about residents is handled correctly. Hollystead DS0000025350.V320702.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): 11,12, 13, 14, 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 provided with opportunities to use community facilities and resources. Individual activities continue to be developed in the home to meet individual needs. Menus offer choice and the food provided takes into account residents individual preferences and any special dietary needs. EVIDENCE: At the start of this visit four residents were at home, all the other residents were out at different support services and gradually returned throughout the day, the majority arriving back about 3.30-4pm. The manager and staff confirmed that residents are supported to access all community services where possible, this includes visiting the cinema, pubs, shops, and theatre to name a few. The home has its own transport which further enables residents to participate in community activities. Since the last inspection the activity organisers post has been filled. The activity organiser spends time with individual residents and keeps a record of what they do. The home has moved away from providing group activities although they do Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 13 occasionally take place. The home has an activities room that has instruments and art and craft materials for residents to use. There is also a sensory room where residents receive sensory stimulation through the use of sight, touch and sound. Hollystead has access to an adapted caravan in Wales in the spring/summer months which many of the residents have visited with the support of staff for either a day or longer. There is a minimal charge for access to this facility. The staff at the home also arrange individual holidays where appropriate which residents help choose in accordance with their abilities or with assistance from their family or staff. The inspector was informed that a number of residents are to be supported to go to Lourdes later in the year. As previously stated many residents go to day services during the week so the times for getting up are governed by this, at weekends they can get up and go to bed when they want. On the day of this visit after tea residents were seen spending time in the lounges watching telly, listening to music or doing something they want to do e.g. playing a game. A couple of the residents chose to spend time in their rooms. The home has an open visiting policy and visitors are welcome at any reasonable time as was observed during this visit, although visits are at the discretion of the residents. Staff also are available to assist residents and their families if there are any difficulties in making arrangements. The home employs a full time and part tem weekend cook (which is currently covered by agency staff). Menus provided show that a wide variety of food is provided and there is always a choice of meal. Specialist dietary requirements are catered for. All meals are served in the dining room and staff are always available to provide assistance where needed. Hollystead DS0000025350.V320702.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans that identify how personal care needs are to be met are in place to ensure individual personal care needs are met. The home has policies and procedures in relation to the management of medicines and staff are provided with training to safe guard residents. EVIDENCE: All residents at the home require varying degrees of assistance with personal care. Each resident has a care plan that provides information for staff as to how their personal care needs are to be met. Any assistance required with personal care is always provided in the service users own room or bathroom and by a member of staff of the same gender. There was a good atmosphere in the home and the staff were seen talking a respectful way to residents and good relationships were seen to have been developed. All service users are registered with a General Practitioner who visits the home at least weekly or more often if required. Appropriate arrangements are also in place for service users to access the services of an optician, dentist, chiropodist or other health care professionals as required and all visits are recorded on individual files. The General Practitioner who visits the home Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 15 arranges for the district nurse to provide the required treatment if a service user develops a pressure area, or if the service user requires assistance from the diabetic nurse and continence advisor. Service users are supported to attend all appointments. The organisation has a comprehensive medication policy and procedure which is kept under review. The staff members who administer medication are clearly identified and all have undertaken a certificated course in relation to administering medication. At the time of this inspection no service users were self- medicating. Inspection of Medication Administration Records (MAR sheets) indicated that records were satisfactorily maintained. Medication is received in blister packs from the chemist and all medication if service users go home for the weekend or attend day centre is in a separate blister packs. Medication is appropriately secured and stored. Hollystead DS0000025350.V320702.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the appropriate policies and procedures in place to protect resident’s rights and ensure their safety. EVIDENCE: The Nugent Care Society has a clear and comprehensive complaints procedure which has recently been reviewed. Basic information on how to make a complaint is displayed in the hallway of the home. An illustrative version of the complaints is available. As recommended at the last inspection a programme of training is to be implemented for staff about dealing with and assisting residents to voice their concerns. No complaints have been received at the home and no complaints have been received by CSCI since the inspection of Hollystead in January 2006. The organisation has a policy and procedures about adult protection and the prevention of abuse, including Whistle-Blowing. A copy of Liverpool City Council’s adult protection procedures is also available for staff to refer to. The manager has a good knowledge of the procedures to be followed should abuse be suspected. The protection of vulnerable adults is included in the home’s induction programme for new staff and all staff attend the on-going training relating to this that is available. Prior to staff beginning work at the home Protection of Vulnerable Adults Check is completed until an Enhanced Criminal Records Bureau check is received. Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 17 Policies in relation to the management of residents money are in place and records kept in line with this policy. Receipts are kept of all money spent on behalf of resident’s, finances were not checked during this inspection. Hollystead DS0000025350.V320702.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, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hollystead provides residents with a safe, homely and well maintained environment EVIDENCE: Hollystead is a spacious Victorian House, set in its own spacious grounds and has off road parking facilities. The original building has been adapted to ensure that the facilities in the house are accessible and available to all residents. A unit was added on the ground floor that is ramped to give easy access to the main part of the building. There are spacious gardens at the front of the building that are well maintained Hollystead provides planned respite care for a maximum of one resident throughout the year. This service has been provided for many years and dedicated facilities are not currently provided although a dedicated room is. On the day of this inspection the home was clean and tidy, maintenance and decoration is on-going in the home. The home has two lounges and a separate dining room, these rooms are in constant use and as a result furniture and fittings need to be regularly replaced. The inspector was informed that additional new furniture is to be purchased for the dining room and the extra Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 19 tables and chairs sent from another home removed. New furniture is to be purchased for the lounge areas as the furniture is showing definite signs of wear. The purchase of this new furniture will greatly enhance the appearance of these rooms. The furniture and fittings in the bedrooms seen were of good quality. A number of service users have been supported by either staff of family to purchase their own furniture. All bedrooms are individual and reflect the personality of the occupant, a number have had laminate flooring fitted. All bedrooms are fitted with an appropriate lock and staff have use of a master key in case of an emergency. The home provides a number of specialist bathing facilities including walk-in showers and tilting baths, it was noted that their was evidence of mould in the shower room on the first floor which needs to be addressed. In addition the home has individual specialist equipment to assist residents with their mobility. Although the house is large, staff have made considerable effort to ensure that the service does not become institutionalised and there are a number of areas where residents can have quiet or privacy if they want. As stated in the previous inspection report it is unusual for adults with a learning disability to be cared for in larger groups. It would be good practice, however for the caring agency to consider providing accommodation for people in smaller groups and in “ordinary’ houses Hollystead DS0000025350.V320702.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, 33, 34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment and selection procedures ensure resident’s rights are protected. On going training is provided to provide staff with the skills and knowledge to ensure residents needs are met. EVIDENCE: Hollystead currently have three staff vacancies, two day care positions and the weekend cooks post that is covered by agency staff, two staff are also currently on long term sick leave. All vacant posts have been advertised. The home is currently staffed as follows there are three care staff teams which comprise of a team leader, four support workers and a domestic, if residents require individualised support, as part of their care package, additional staff are employed. Night staffing levels are as follows: Team leader sleeping in and two waking night staff. Additional support is provided via an on-call system. In addition the home employs an administrator 30 hours per week, a maintenance person 40 hours per week kitchen staff 59 hours per week each and an activity organiser 25 hours each week. Comprehensive on going training is provided for all support workers in health and safety, food hygiene, infection control, moving and handling, fire safety Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 21 and first aid. Additional training is provided in person-centred planning, positive intervention/challenging behaviour and other areas identified to ensure residents needs can be met. Three staff are completing NVQ 2 and 9 staff have completed this award. The home has employed a number of new support staff over the past twelvemonths and evidence was available that the organisation had ensure that Protection of Vulnerable Adult checks and Enhanced Criminal checks had been completed as part of their recruitment practices before staff had begun working at the home. Examination of staff files showed that they did not contain a photograph of the staff member, this should be addressed. All new staff complete an induction programme when they begin work at the home. The inspector was able to talk to the team leader on duty in the afternoon about the induction they had completed when joining the staff in November. and they felt is was comprehensive. Staff spoken to made comments about how they enjoyed their job, and both agency staff who were on duty in the evening confirmed that staff were helpful and made them feel welcome. Both agency staff informed the inspector that they had worked at the home on a number of occasions and were aware of residents needs. Due to current staff vacancies and the long term sickness of two staff agency staff have been used regularly over the past months. The manager is aware of the need to maintain continuity of care for residents and the organisation use the same agency to provide staff in order to try and maintain continuity where possible. The inspector was informed that interviews for relief staff had recently taken place and five staff appointed, further interviews are to be held. With the increase in relief staff in the agency the need to use agency staff will decrease. Comments were made in the survey forms returned by relatives/carer of people living at Hollystead about the use of agency staff and the impact on continuity of care. Records were available to show that staff had received supervisor and appraisals, however supervision had not been provided at the appropriate intervals and the manager is aware that this should be addressed. Hollystead DS0000025350.V320702.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, 38, 39,and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the residents. The home is well maintained to ensure the safety of residents. EVIDENCE: The registered manager has many years experience in caring for and supporting vulnerable adults and managing a staff group. She currently holds the CSS qualification and has completed the registered managers award, the A award relating to NVQ assessment and undertakes training to keep her knowledge up to date. The manager provides clear guidance for staff and is always available to offer support and guidance. Since the restructuring of the management team the manager is supported by three full time and one acting part time team leader. Each team leader has allocated specific responsibilities and is responsible for managing their individual team and providing supervision. All team leaders have obtained an National Vocational Qualification Level 3 (NVQ) and received training in Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 23 providing supervision, administration of medication as well as mandatory and specialist training required to meet residents needs. The inspector was informed that all team leaders are to undertake the training to become NVQ assessors. Team Leaders receive formal supervision from the manager, regular senior team meetings are held and one took place during this visit There are a number of systems in operation to monitor the service provided by Hollystead. Regulation 26 visits are made to the home, which involve carrying out an audit of different areas of how the home operates, the records kept and involves talking to residents and staff. A member of The Nugent Care Society’s Quality Assurance Team visits the home periodically. During these visits a random number of areas identified in the National Minimum Standards are inspected and findings recorded in the Quality Assurance annual plan. Any areas requiring attention are identified and actions taken to address issues are recorded, the inspector was able to see records of the last visit. The manager recently sent survey forms asking about the service provided at the home to all families/carers of residents who live at Hollystead, to those who receive respite and stakeholders. A random sample of records held in the home were checked, these included, water temperatures, PAT testing and fire safety. All were satisfactory. In addition the manager completed a pre-inspection questionnaire prior to this visit which provided additional information that equipment is serviced on a regular basis and a number of health and safety checks routinely completed to ensure the safety of staff and residents service users. Environmental and safety risk assessments are in place that are regularly reviewed. The Employers Liability Certificate was up to date. Hollystead DS0000025350.V320702.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 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X X 3 x Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 25 No 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 18 Requirement The registered person should ensure that cause of the mould in the shower room is investigated and addressed. addressed Timescale for action 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard YA34 YA6 YA36 YA41 Good Practice Recommendations Staff records should contain a photograph of the person employed. The home should continue to develop the ‘Person Centred’ system of care planning introduced to develop the individual skills and competences of residents. Care staff should receive supervision at the intervals recommended in the NMS. To ensure all completed documentation is signed. Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Hollystead DS0000025350.V320702.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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