Inspection on 10/06/05 for Hoyland Hall

This inspection was carried out on 10th June 2005.

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

Other inspections for this house

Hoyland Hall 01/11/06

Hoyland Hall 27/09/05

Hoyland Hall 17/11/04

Hoyland Hall 21/04/04

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

CARE HOMES FOR OLDER PEOPLE Hoyland Hall Market Street Barnsley South Yorkshire S74 0EX Lead Inspector Jayne White Unannounced 10 June 2005 08:30am 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 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. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hoyland Hall Address Market Street Barnsley South Yorkshire S74 0EX 01226 745480 01226 742622 Not known Healthmade (Hoyland Hall) Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant PC Care Home Only 40 Category(ies) of OP Old age (40) registration, with number of places Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 40 beds may instead be used for PD - Physical Disability, for persons 60 years and above where the physical disability is related to the aging process. 2. Staffing must be provided at, at least, the levels specified by `Residential Forum Care Staffing in Care Homes for Older People` published April 2002. 3. The Manager`s hours (37 per week) must be over and above those specified at Condition 2. Date of last inspection 17th November 2004 Brief Description of the Service: Hoyland Hall is a care home providing personal care and accommodation for 40 older people. The homes registered owner is Healthmade (Hoyland Hall) Limited. Hoyland Hall is situated off the main road, close to the town centre at Hoyland, Barnsley, giving easy access to all local amenities and shops. The home is a two-storey home. The home stands in its own grounds and has a garden area that is accessible to residents. There are car-parking facilities at the front of the building. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six and a half hours from 8:30 to 14:30. Amanda Lindley, regulation manager accompanied Jayne White on the inspection. Opportunity was taken to make a partial tour of the premises, inspect a sample of records, observe care practices and talk to residents, relatives, another professional, the staff and manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to three of the staff on duty about their knowledge, skills and experiences of working at the home, three residents about their views on aspects of living at the home and three relatives. What the service does well: The statement of purpose contained relevant information for residents so that they could make an informed choice of where to live. The main lounge area at the home is also the smoking area although another smoke free lounge is provided but is on the first floor. Residents who had been admitted to the home had, had their needs assessed and the home had confirmed by letter and the issuing of a contract that they could meet their needs. Residents felt they were treated with respect and their right to privacy and dignity upheld. Residents were pleased with their living environment including the dining area and with the majority of meals that were served. Residents and relatives had no complaints but said they would be happy to approach staff if they had. Staff members were trained in adult protection and said they would report any abuse if they became aware of it. The cleanliness of the living environment had been maintained and the home presented well. The member of staff that worked in the laundry should be commended on the pride they take in providing a good laundry service to residents. Staff were undertaking training, which enabled them to meet the needs of the residents in the home. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 6 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. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 & 3. Standard 6 is not applicable to the home. The statement of purpose contained relevant information for prospective residents so that they could make an informed choice of where to live. The service user guide did not. A written contract/statement of terms and conditions was in place for the resident whose file was inspected. Residents who had been admitted to the home had, had their needs assessed and the home had confirmed by letter and the issuing of a contract that they could meet their needs. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 9 EVIDENCE: A statement of purpose, service user guide and contract for residents were in place. The manager was asked to include the information about the arrangements for the smoking area in the statement of purpose and not refer prospective users to the service user guide, where the information was included. The service user guide did not include all the details required. There was a notice board in the grounds that identified the home provided nursing care when the home is not now registered to provide this type of care. The contract of one resident was inspected. The contract included the details required but did not identify who the fee was payable by. The admission assessments of two residents were inspected – one was selffunding, the other placed through care management arrangements. Both had a pre admission needs assessment completed by the home. Consistency was not maintained in that they were consistently dated and signed. One date had been crossed out and replaced. The manager agreed that when the resident had been admitted for permanent care a new admission assessment had not been completed because the details remained the same. This was discussed with the manager. For the resident admitted through care management arrangements a copy of the summary of that assessment had been received by the home. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 The information in one care plan was inadequate to ensure that the resident’s health needs were being fully met. One other care plan inspected was satisfactory. A range of health care professionals visited the home to assist in maintaining the health care needs of residents. Residents themselves said that they were satisfied with the care they were receiving and that the staff were friendly, helpful and polite. Residents were protected by the homes policies and procedures for the receipt, storage and records of medication but not for the recording of medication that was being administered. Residents felt they were treated with respect and their right to privacy and dignity upheld. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 11 EVIDENCE: Care plans were well indexed and on the whole included relevant information about the residents. One care plan was inspected in depth. The care plan and thus the daily report did not wholly reflect the care provided for the resident in regard to their health care needs and did not reflect a district nurse had become involved in their care. Documented risk assessments were in place in regard to the resident maintaining control of their keys and finances and the plan had been drawn up with the involvement of the resident and/or their advocate and agreed and signed by them. Staff could clearly state how they assisted residents with their personal care and residents said staff offered this appropriately as and when needed. Observations during the inspection together with discussions with residents confirmed they had appointments with a range of healthcare professionals. The inspector observed the administration of medication to residents. Medication was signed for prior to it being administered to the residents. The regulation manager inspected the receipt, storage and records of medication. This was satisfactory. Residents said their privacy and dignity was respected and staff were able to describe how they maintained residents privacy and dignity. The regulation manager observed that residents were wearing clean clothes and appeared to have received an acceptable level of personal care. Relatives that were spoken with confirmed ‘they always found mum clean and well presented’. There was a telephone in the home for residents to use that was located in the hallway of the home, however, all residents rooms have telephone points and the telephone could be transported there when required. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 There was an adequate catering service that residents found to be in the main satisfactory. EVIDENCE: Comments from three residents about food served at the home included ‘food at tea time on the week of the inspection was not nice’, ‘meals are alright but the odd occasion when it isn’t’, ‘fish and chips were lovely and the hot pudding was nice’ and ‘food is good but sometimes better than others. One relative said they were offered a meal when they visited. There was not a menu on display to show the daily menu and options available. Three full meals a day were offered. Nutritional risk assessments were included in residents files inspected. The inspector observed breakfast and the regulation manager the lunch. Residents were given sufficient time to eat their meals and where residents required assistance with eating this was done discreetly, sensitively and individually. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Residents and relatives had no complaints but said they would be happy to approach staff if they had. Consistency was not maintained in that all complaints procedures used by the home were the same. There were appropriate protection policies in place, however, the actual policy needed to refer to the procedures for reporting abuse. Staff members were trained in adult protection and said they would report any abuse if they became aware of it. EVIDENCE: The complaints procedure identified in the statement of purpose and service user guide was resident friendly, comprehensive and included all the information required by the regulations, however, the one displayed in the entrance hall differed to that identified in the statement of purpose and service user guide and did not include a timescale to guide complainants. No complaints had been made since the last inspection. Relatives and residents said they had no complaints and if they had they would have no problems approaching the staff. The inspector looked at the homes adult protection policy. The policy did not include the procedure to be followed if an allegation of abuse was made, however, the manager said the local multi agency procedures would be used and the home had copies of these. Staff had, had training in adult protection and confirmed they would report abuse if they were aware of it. On recruitment, staff were appropriately checked against the’ Protection of Vulnerable Adults Register’. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 25 & 26 The building and its surroundings were generally clean and on the whole well maintained, thereby enhancing its appearance and facilities. The residents spoken with said they felt the home offered a comfortable standard of accommodation. Improvements had not been made in the provision of soap and paper towels in toilet and bathroom areas to control the spread of infection. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 15 EVIDENCE: The inspector and the regulation manager both undertook partial tours of the home. The cleanliness of the living environment had been maintained and the home presented well. There were no malodours. The communal areas and some residents private rooms that were viewed were in a good decorative state. The furnishings and fittings were domestic in character. It was noted maintenance work was in progress to three bedroom areas to enhance their living environment. There was a pleasant sheltered patio seating area outside with access through one of the lounge areas. There were no CCTV cameras in the home. The outside and entrance to the home were appropriately CCTV monitored. The grounds were tidy and accessible. The main lounge area at the home is in two halves, with one half being used as the smoking area although another smoke free lounge is provided on the first floor. The home did have an appropriate amount of sitting, recreational and dining space and there were sufficient rooms for a variety of activities to take place. Residents could see visitors in private in their own rooms. The dining area was large enough to cater for all residents. All areas of the home were accessible to people in wheelchairs. The lighting levels were satisfactory. All rooms were centrally heated. The heating in residents rooms could be individually controlled but residents would need to seek assistance to do this. The water temperature was inspected and was satisfactory. Laundry facilities were sited away from all food preparation and storage areas. The laundry floor had an impermeable floor covering and the walls were washable. Hand washing facilities were provided together with soap and paper towels. Disposable gloves and aprons were available. The bathroom and toilet areas did not consistently have in place soap and paper towels to control the spread of infection. The home had a sluice. Equipment provided in the laundry was in working order. The member of staff that worked in the laundry should be commended on the pride they take in providing a good laundry service to residents. Care was taken that all laundry was carefully folded and placed in the appropriate box to be returned to the resident. The staff member that worked in the laundry continued to require appropriate training but this had commenced and as completion of the training will take some time the requirement has been removed but progress will be monitored on future inspections. The staff member could verbally describe the processes they used to control the spread of infection including specialist washes and laundry that required sluicing. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The residential staffing forum calculation and staff rota did not confirm that the condition of registration to identify staffing hours sufficient to meet the needs of the residents were met. Although there had been improvements in the recruitment information obtained for new staff it remained insufficient to adequately protect the welfare of residents who lived at the home. Staff were undertaking training, which enabled them to meet the needs of the residents in the home. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 17 EVIDENCE: The home had two conditions of registration in regard to their staffing arrangements. One, the home must now meet the staffing forum guidance recommended by the Department of Health and the other that the manager must work 37 hours over and above those hours identified by the guidance. The last staffing forum calculation provided was on 20 December 2004 when 25 residents were in residence. The total care hours for that week was 427.78. The total care hours required for the week of the inspection using the staffing forum calculation was 589.32, using information provided by the manager. The actual care hours worked using the staff rota provided (not deducting the hours worked in the kitchen by carers and breaks) was 504. This included that the layout of the building did have an effect on the provision of care to residents as the home is sited over two floors, there are isolated corridor areas and residents choose to spend their time in various parts of the building. It also included that additional cover was required for residents who required special assistance as discussions with staff identified there was one resident who required the use of a hoist and residents who required assistance with feeding. The manager and the company continue to disagree with including these aspects in the hours required. In addition, at the tea time meal and at supper time care staff worked in the kitchen to provide cover and those hours had not been removed from the calculation of minimum care hours required. Discussions with staff identified they could do with more staff to ensure their tasks were completed thoroughly particularly on the afternoon shift. This was one area within the home where they thought standards could be improved. Two weeks rotas were provided as the others had been sent to head office and were not available. This identified that the manager had not worked 37 hours over and above staffing forum guidance. There was information on the staff rota that was unable to be understood, for example 61 and L. In addition the rota did not identify the number of hours worked by all staff. The rota for the week of the inspection identified four staff on the morning shift and three on the afternoon and night shift. One staff file was inspected. The recruitment process had improved since the last inspection, however, there was still information required including documenting that gaps in employment have been explored and a statement by the person that they are physically and mentally fit to work at the care home. The one in place was not adequate. The file demonstrated a training record was being maintained and that the member of staff had undertaken appropriate induction training. Discussions with staff identified they were receiving ongoing appropriate training and that policies and procedures were available in the treatment room. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 37 & 38 The inspector was unable to confirm residents financial interests were safeguarded, as previous requirements requiring records of financial transactions to be kept at the care home had not been met. Improvements were required with some of the records kept by the home to ensure the residents rights and best interests were maintained. Some areas relating to health and safety issues required further attention, in order to enhance the safety and welfare of both residents and staff. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 19 EVIDENCE: The inspector was unable to inspect the finance records of residents, as previous requirements for financial records of residents to be kept at the home had not been met. The inspector checked a sample of the records that the home is required to keep. They did not always contain all the details required by the regulations and standards and were not all up to date and accurate. These have been identified in the requirements made. Records were stored securely. The residents safety and welfare were in part safeguarded by providing staff with training on a range of topics including moving and handling, first aid, food hygiene, health and safety and infection control. The accident book was being completed and now complied with current data protection principles, however, the accident recording sheet had not been removed and filed appropriately. All notifiable incidents were now being reported. A tour of the building identified no fire exits were blocked indoors, however, a path leading from a fire exit was partially blocked with an old chair, footstools and other paraphernalia. The manager was asked to remove these on the day of inspection. She confirmed she would and said they were waiting for a skip. Fire instruction/drill was inspected for four members of staff. In the last 12 months only two members of staff had attended the required number of drills. Regular maintenance checks of the fire alarm, fire extinguishers and emergency lighting had again lapsed and were last checked 4 May 2005, 28 April 2005 and 20 April 2005 respectively. Certificates were available to demonstrate the fire alarm, emergency lighting, fixed electrical circuits; gas and lift had been serviced. There are appropriate measures in place to ensure the security of the premises and prevent intruders. No hazardous substances were inappropriately stored. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 2 x x x x 3 2 STAFFING Standard No Score 27 1 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x 2 2 Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Requirement The service user guide must contain all the details required by the regulations and standards. Previously required on all inspections from 1/4/02. Assessments must be consistently dated and signed. Current health care needs of residents must be identified in their individual plan of care. Medication that is being administered must be signed for after it has been administered to the resident. Residents must be consulted about the tea time meals and the outcome actioned. The consultation must be documented. The adult protection policy must be reviewed to include the procedure to be followed if an allegation of abuse was made. Previous timescale of 31 March 2005 not met. Supplies and equipment to control the spread of infection must be in place. Previous timescale of 31 January 2005 not met. J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Timescale for action 31 October 2005 2. 3. 4. 3 7&8 9 14 15 13 31 August 2005 31 August 2005 31 August 2005 31 October 2005 5. 15 24 6. 18 13 31 October 2005 7. 26 13 31 August 2005 Hoyland Hall Version 1.30 Page 22 8. 27 9. 27 10. 27 11. 29 12. 33 The number of staff hours provided must be in accordance with that required using the staffing forum guidance recommended by the Department of Health. Previous timescales of 31 December 2003, 30 June 2004 and 31 January 2005 not met. CSA 2000 The manager must work 37 Section 13 hours over and above the staff hours provided using the staffing forum guidance recommended by the Department of Health. Previous timescales of 30 June 2004 & 31 January 2005 not met. 18 When care staff are undertaking other duties than care these must be identified on the staff rota and removed from the calculation of care hours when identifying care hours provided using the staffing forum guidance recommended by the Department of Health. Previous timescale of 31 January 2005 not met. 19 Staff recruitment procedures must comply with the regulations and standards. Previous timescale of 30 June 2004 & 31 January 2005 not met. 24 An effective quality assurance system must be put in place based on seeking the views of service users to measure the success in meeting the aims and objectives of the home. The system must cover all areas to meet the National Minimum Standards. Previous timescale of 31 May 2004 not met. 18 31 August 2005 31 August 2005 31 August 2005 31 August 2005 30 June 2005 Not checked on this inspection Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 23 13. 35 17 & 25 14. 37 17 15. 16. 17. 38 38 38 23 23 23 Written records of all financial transactions including payment of fees and personal allowances must be kept at the care home. Previous timescale of 31 January 2005 not met. Records required by regulation for the protection of residents and for the effective and efficient running of the business must be maintained, up to date and accurate. The large items partially blocking the path leading from a fire exit must be removed. All staff must have the appropriate number of fire instruction/drills. Regular maintenance of the fire alarm, emergency lighting and fire equipment must be maintained. 31 August 2005 31 August 2005 10 June 2005 31 August 2005 31 August 2005 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. 5. Refer to Standard 1 1 1 2 16 Good Practice Recommendations The statement of purpose should not refer prospective users of the service to other documents to find out information about the smoking arrangements at the home. The company should identify in the statement of purpose and service user guide the date when the plan to enclose the smoking area is going to be. The notice board advertising the home should be replaced to accurately reflect the registration category of the home. The terms and conditions/contract for service users should include a breakdown of the fee and who is responsible for the payment of that fee. Consistency must be maintained in that the same complaints procedure containing all the requirements of the regulations is displayed in the entrance hall, statement of purpose and service user guide. J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 24 Hoyland Hall 6. 7. 8. 9. 10. 20 27 27 27 27 11. 38 That the main lounge area becomes a smoke-free lounge and another area is designated for smoking. The hours worked by all staff should be included in the staff rota. The staff rota should be clear, for example 61 and L was unable to be understood. Staff rotas should be kept at the home. The home should include the layout of the building does cause some difficulty in providing care to service users and one or more service users require special assistance in the calculation of care hours required using the staffing forum guidance recommended by the Department of Health. The accident reporting record should be removed and filed appropriately. Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unit 3, Ground Floor Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 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 Hoyland Hall J51 S6485 Hoyland Hall V230018 10.06.05 UI Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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