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Inspection on 04/04/07 for Little Holland Hall Nursing Home

Also see our care home review for Little Holland Hall Nursing Home for more information

This inspection was carried out on 4th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspector continued to be impressed with the standard of care and communication skills of the staff. Interactions heard were very good and demonstrated staff helping the residents to make decisions about their day-today life rather than make the decisions for them. There was a relaxed and friendly atmosphere throughout the home, commented on by residents and visitors. Activities were varied and catered for the assessed needs of the residents. Mixing with the people from the other parts of the housing site expanded the resident contacts and was felt to be beneficial. Documentation of activities undertaken supported the outcomes expected. Residents` monies were kept and documented safely. Residents and their relatives were assured that the residents were protected from financial abuse by the procedures followed. Procedures for handling residents weekly allowances continue to be good and the administrator ensures that all residents are protected from financial abuse.

What has improved since the last inspection?

A permanent manager has now been recruited for this home and had been in post for two months at the time of the site visit. Ongoing maintenance and redecoration of some areas was apparent throughout. Malodours were not detected at any time, in any area of the home, during the site visit. Documentation of activities undertaken by individual residents had improved since the last inspection. Evaluation of the worth of each activity to the residents demonstrated a commitment to help them take part in individually preferred activities on a day-to-day basis.

What the care home could do better:

At the time of the site visit the statement of purpose and service users guide was in the process of being updated, to include details of the newly appointed manager. Care staff need to take more time to re-evaluate various risk assessments for individual residents to ensure that the care offered is for their most current needs.

CARE HOMES FOR OLDER PEOPLE Little Holland Hall Nursing Home Frinton Road Holland On Sea Essex CO15 5SS Lead Inspector Lysette Butler Key Unannounced Inspection 4th April 2007 08:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Holland Hall Nursing Home Address Frinton Road Holland On Sea Essex CO15 5SS 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) 01255 813402 01255 813962 Ellerash Limited Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability (41), Physical disability of places over 65 years of age (41), Terminally ill (3) Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Persons of either sex, aged 60 years and over, who require nursing care by reason of a physical disability (not to exceed 41 persons) Persons of either sex aged 40 years and over, who require nursing care by reason of a physical disability (not to exceed 8 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 41 persons) Persons of either sex, aged 55 years and over, who require general palliative care (not to exceed 3 persons) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 3 persons) The total number of service users accommodated must not exceed 41 persons 16th January 2006 Date of last inspection Brief Description of the Service: Little Holland Hall is situated in Holland on Sea, North Essex. It is part of a larger complex that includes sheltered housing; warden controlled flats; and privately owned homes for older people. Near to the nursing home, on the same site, there is a two storey listed building. Ellerash Ltd, which is part of the Care UK group, owns the Little Holland Hall complex. Care UK is a national care organisation. This nursing home has 41 single rooms divided between two floors. All of the rooms have en suite facilities. The home offers nursing care for up to 41 older people. Within this number, three beds are also registered for residents with palliative care nneds. The home is not registered for dementia care. Current resident fees range between £600 and £700, per week. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The inspection process included: a site visit on 4th April 2007, which lasted 7 hours; review of evidence supplied by the proprietor, residents, visitors to the service or the staff; resident, visitor, healthcare professionals and staff surveys; discussions with the acting manager, senior carers, care staff, ancillary staff, residents and relatives. During the site visit the premises were inspected, including inspection of the grounds. Samples of records and residents’ care plans were also reviewed. The home was clean, airy and well maintained. The overall care and well being of the residents was the focus of the inspection. Staff and residents were welcoming and happy to speak to the inspector at the site visit. This inspection covered all twenty-two key standards and eight of the remaining standards. The manager and her staff approached the inspection in a positive and cooperative manner that was focused on achieving best practice to meet the needs of the residents. What the service does well: The inspector continued to be impressed with the standard of care and communication skills of the staff. Interactions heard were very good and demonstrated staff helping the residents to make decisions about their day-today life rather than make the decisions for them. There was a relaxed and friendly atmosphere throughout the home, commented on by residents and visitors. Activities were varied and catered for the assessed needs of the residents. Mixing with the people from the other parts of the housing site expanded the resident contacts and was felt to be beneficial. Documentation of activities undertaken supported the outcomes expected. Residents’ monies were kept and documented safely. Residents and their relatives were assured that the residents were protected from financial abuse by the procedures followed. Procedures for handling residents weekly allowances continue to be good and the administrator ensures that all residents are protected from financial abuse. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed before moving into the home ensuring that their care needs will be met. EVIDENCE: During the site visit to this home draft copies of the new Statement of Purpose and Service User Guides were reviewed. Both documents contained appropriate information to enable prospective users of the service to make the correct choice regarding admission. Copies of the updated and agreed documents will be sent to the local office of the Commission for Social Care Inspection upon completion, where they will be filed accordingly. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 9 During this visit four resident care plans were reviewed all contained original admission assessment documentation in line with Care UK policy and procedures. One resident spoken to who had been admitted to the home two month’s before the site visit confirmed that the pre-admission assessment covered all areas of care that they required. Intermediate care is not offered at this home. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans were detailed and covered all the needs of the individual. However risk assessments need to be continually updated to ensure that the most current needs of the residents are being cared for. Medication policies and procedures protect the residents from harm and residents were clearly treated with respect and sensitivity. EVIDENCE: Care UK operates a computerised care planning system throughout their nursing and care homes, called Saturn. The Commission for Social Care Inspection has reviewed the Saturn system nationally and the inspector for this home was enabled to review care plans on the system during the site visit. A total of four resident care plans were reviewed. The overall standard of care plans was good they were regularly reviewed; evaluations and daily records were of a good quality. However some risk assessments have not been kept up-to-date since the retirement of the previous deputy manager. These lapses Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 11 were discussed with the new acting manager during the site visit. The inspector and the manager discussed how the residents input to their own care plans could be documented. At the time of this visit the staff were about to start inputting the resident’s picture to the Saturn system, although all medication administration records already contained a picture of the individual residents. Health care practices were good and documentation demonstrated a commitment to meeting all individual needs. There were several instances of how needs were met observed during the site visit. Staff demonstrated caring and thoughtful interactions with residents. Residents told the inspector that staff were very helpful and made sure that they were comfortable at all times. The home provides escorts for residents attending hospital appointments if no family member is able to attend. All medication administration records were reviewed throughout the home. There were no omissions; entries were clear; changes were dated and signed; and Care UK policies and procedures were being followed. There had been a medication inspection by a specialist pharmacy inspector on behalf of the Commission for Social Care Inspection, since the last key inspection. This inspection had been in response to concerns raised by a relative. During this inspection none of the concerns raised were found and the specialist inspector was impressed with the overall procedures followed, with regard to all aspects of the storage and administration of medications in this home. During the site visit undertaken as part of the current inspection process, the inspector found that all procedures were still being carried out to a high level. There was no overstocking of medications found anywhere in the home; all controlled drugs were reviewed and showed that documentation was excellent throughout; homely remedies had all been bought ‘over-the-counter’ and were in date; the medication room was air-conditioned; room and fridge temperatures were taken and recorded daily; and the interactions between staff and residents, observed during the medication administration ‘rounds’, were of a very high standard. Discussion with residents and visitors; observation of interaction between staff and residents on the day of the inspection; and documentation reviewed made it clear that residents are treated with respect and core values such as privacy and dignity are maintained. For example, staff were seen to knock on residents bedroom doors and wait for a response before entering. During a tour of the home on arrival, the inspector observed care assistants hoisting residents maintaining their dignity throughout the procedure. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 - Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Choice in daily life decisions and social activities is standard in this home. Residents are encouraged to lead their lives as independently as possible dependant on the severity of their ongoing condition. EVIDENCE: During the site visit the inspector reviewed activities available with residents and visitors, but was not able to speak to the coordinator. Residents and visitors were very happy with the individualised and scheduled group activities offered. Residents felt they were given choice and that the activities offered suited their needs. The coordinator tries to ensure that all residents have one to one time with either her, or one of the carers. During this time the coordinator, or carer, took time to assess the individual resident’s likes and dislikes. Little Holland Hall is part of a larger complex (see Brief Description of the Service,) and the activities coordinator also arranges activities with the residents in other parts of the complex to enable broader interaction for all residents in the complex. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 13 Documentation on the Saturn system (see Health & Personal care section,) was very good; it evaluated activities undertaken and the usefulness of those activities to the individual. Evaluation notes were entered on each occasion the resident took part in group, or individual activities. A review of the care plan items attached to activities are reviewed monthly by the activities coordinator or the key worker for the individual resident. Residents are encouraged to keep contact with family and friends, with open visiting practices as routine. Visitors said that they were always made welcome and they felt that they could talk to the manager or her staff about anything. Visitors spoken to also said that they felt their relatives were offered very good care and that staff in the home “….are excellent.” During the site visit residents were observed being given choice, time and consideration in all interactions. Residents and visitors said that food choice and quality was “…excellent.” Menus reviewed demonstrated a wide range of meals offered and that there was a number of choices at each mealtime, with the proviso that if there wasn’t ‘anything they fancied’ on the list they could ask for something different. The lunchtime meal offered a good choice and care assistants were observed giving residents choice in what they wanted to eat and the quantity required. Some residents eat in their rooms and one told the inspector they preferred “….eating alone, but still enjoyed socialising in the lounge afterwards.” There is a servery on each floor where the staff distribute the meals from, to ensure they are as warm as possible when they reach the individual resident. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, their relatives and friends can be confident that the residents of this home are safe and protected from abuse. EVIDENCE: The Commission for Social Care Inspection had not received any complaints about this home since the last key inspection. The acting manager had received one substantial complaint since commencing at the home, which may trigger a Protection of Vulnerable Adults referral in the future. The inspector and acting manager discussed the issues raised during the site visit and the inspector was satisfied that the manager was following Care UK complaint procedures appropriately. The manager confirmed that she would notify social services of any Protection of Vulnerable Adults issues if appropriate. Review of the complaints file recorded two further verbal concerns that had been dealt with appropriately by the acting manager. Yearly Protection of Vulnerable Adults training for staff was in process at the time of the site visit. Review of staff training records demonstrated a commitment to regular updated training that is received by all staff. The acting manager had also ordered new Essex Protection of Vulnerable Adults booklets to be distributed when received, to ensure that all staff have the most up to date information. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a calming, happy atmosphere in this home that is appreciated by the residents and their visitors. EVIDENCE: The inspector on arrival made a complete tour of the home. Considering the time of day, the home was bright, airy and clean. There were no malodours throughout and the cleaning staff obviously took pride in their work. Although the environment was not a focus of this inspection, communal areas and individual rooms seen during the inspection appeared nicely decorated and well maintained, containing various amounts of the residents’ personal belongings. On each floor there is a bookcase with a selection of books and magazines for the residents to use. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 16 Storage space in this home is lacking, but the staff make the best use they can of the space available and the corridors were generally clear of obstructions. Staff spoken to were able to demonstrate an awareness of the safety needs of the residents and the environment. All hoists and electric baths had been serviced within the previous six months. All CoSHH items, throughout the home were stored appropriately. Sluices were clean and tidy. Bathrooms were safe, clean and free from obstructions. Infection control procedures in the home are good and staff understand their importance. Alcohol gels were evident throughout the home; staff and visitors are encouraged to use them on entering each room. The manager was in the process of arranging for a visit by the local Primary Care Trust infection control specialist to ensure they are carrying out all procedures necessary to protect the residents. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident needs continue to be met by qualified, trained and competent staff that are recruited in a professional and safe manner. EVIDENCE: Staffing levels and skill mix have not changed since the last inspection and still allow for a minimum of two registered nurses and five care staff on duty during the day and one registered nurse and three care staff during the night time period. There is support from the acting manager, deputy manager and administrator, who are generally supernumerary to these levels. At the time of the site visit there were three housekeeping staff on duty and there were separate staff for the laundry and kitchen areas. The maintenance staff from the larger site and the home itself, work together to ensure that one of them is always available to cover the needs of the home. Residents and visitors told the inspector that they were very happy with the quality of the care they received. At the time of the site visit one care assistant was undertaking National Vocational Qualification’s at level 2 and four further care assistants were about to enrol. The acting manager had been a National Vocational Qualification assessor for the Registered Managers Award level 4, previous to commencing this post. She intends to be involved with the National Vocational Qualification Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 18 training in the home to ensure that the present level of 44 of care staff with qualifications is improved upon. Three personnel files were reviewed during the site visit. The information required is all ‘logged’ on the Saturn system with written information kept in separate well-maintained document files. Recruitment procedures were good to ensure the safety of the residents. Nursing & Midwifery Council registrations are checked regularly and the manager keeps an up-to-date list of when each registered nurse’s registration is due for renewal. Each member of staff has an individual training record both on Saturn and in paper versions. All staff spoken to stated that they were offered a lot of training opportunities, both statuary sessions and specialist subjects. Night staff regularly attend training sessions. Some sessions were undertaken in the evening to accommodate those night staff that are unable to attend training during the day. One of the senior care assistants is a National Vocational Qualification assessor and takes responsibility for booking training and maintaining up to date records of attendance. The system works well and the acting manager is intending to maintain this arrangement. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 & 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of this home continues to be good and residents are cared for in a safe environment by knowledgeable staff. EVIDENCE: There have been a number of interim management arrangements in place since the last key inspection, following the promotion of the previous registered manager. At the time of the site visit the new acting manager had been in post for approximately two months, she is a registered nurse with previous National Vocational Qualification assessment experience. She is in the process of completing her Commission for Social Care Inspection manager application pack, which will be sent to the regional registration team when complete. The acting manager and inspector discussed the management of the Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 20 home, at which time the manager demonstrated a very good knowledge of the needs of the residents and staff. The acting manager as necessary will further review management structures and responsibilities within the home over the next few months. Staff and residents spoken to said that they were getting used to the new manager, “….. it is always strange getting used to a new manager, but she seems very nice.” The acting manager had undertaken a recent resident survey and it was agreed that she would be sending an evaluation of these surveys to the local office of the CSCI when completed. The new manager has also asked for a detailed Care UK internal audit of the home as soon as possible, to back up her initial impressions of the adjustments needed. There has not been a full Care UK internal audit of the home for some considerable time. The acting manager is also utilising resident involvement forms on a regular basis in an appropriate manner. She is also encouraging staff to fill in forms as well so that they feel part of the overall process. There have been no changes to the way in which resident monies are handled and during the site visit five resident accounts were reviewed; all were correct and the records were excellent. The procedures used were logical and efficient making them very easy to follow. Three residents were currently looking after their own finances. The administrator was very clear about her responsibilities regarding protection of vulnerable adults and how to sort out problems as they occur. All record keeping throughout the home was very good especially with regards to administration procedures and general care planning on Saturn. Documentation is stored appropriately to protect confidentiality. However all of the policies and procedures for this home are produced centrally by Care UK and reviewed nationally by the Commission for Social Care Inspection Provider Relationship Manager for Care UK. All certificates and servicing records seen at this inspection were up-to-date and appropriate for this home, ensuring the health and safety of the residents. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 4 X 3 3 Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 4, Schedule 1 Requirement The most up to date copies of the homes statement of purpose & service users guide must be available for prospective residents and their families, to ensure that they have the correct information to allow them to make the right choice of home. Resident risk assessments must be kept up to date to ensure that the care given to the individual residents is applicable for their current needs. Timescale for action 30/07/07 2 OP7 13(4b-c), 15, Schedule 3(1b) 30/07/07 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 Refer to Standard OP31 Good Practice Recommendations The acting manager should make application to the Commission for Social Care Inspection for registration as manager, in a timely fashion. Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Little Holland Hall Nursing Home DS0000015325.V334945.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!