Inspection on 16/11/06 for The Hollies

This inspection was carried out on 16th November 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Hollies 05/11/08

The Hollies 27/01/06

The Hollies 13/07/05

The Hollies 20/01/05

The Hollies 06/07/04

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Snydale Care Home

Hawkhills

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The Grove Waltham

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

CARE HOMES FOR OLDER PEOPLE The Hollies 27 Church Lane Garforth Leeds West Yorkshire LS25 1NW Lead Inspector Paul Newman Key Unannounced Inspection 16th November 2006 10:00 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 The Hollies DS0000001462.V311791.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. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 27 Church Lane Garforth Leeds West Yorkshire LS25 1NW 0113 287 1808 0113 2875591 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) Garforth Residential Homes Limited Mrs Nicola Berry Care Home 28 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14) of places The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: The Hollies is a care home owned by Garforth Residential Homes Limited and is situated in Garforth, a suburb of Leeds. The home provides personal care and support to twenty-eight older people. Within these numbers, the home is able to accommodate fourteen residents who have dementia. Nursing care is not provided but the home is supported by local healthcare services including specialist services that provide psychiatric advice and support. The property is an Edwardian building, with a more modern purpose built extension and all rooms are single occupancy. The grounds include car parking facilities, and shrubs to the perimeters of the grounds. The companys sister home, St. Armands Court is situated across the courtyard. The home has a passenger lift and communal facilities include a conservatory, three lounges and a dining room. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by the assessed quality rating of the home. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a visit to the home. All regulated services will have at least one key inspection before 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people living at the home. All core National Minimum Standards are assessed and this provides the evidence for the outcomes experienced by residents. At times it may be necessary to carry out additional visits, which might focus on specific areas like health care or nutrition and are known as random inspections. The last inspection was on 27 January 2006. At that time the home’s quality rating was level 3 (good), and no random visits have been needed since then. This visit was unannounced and carried out by one inspector over one day on 16th November 2006. The purpose of the visit was to make sure the home is being managed for the benefit and well being of the residents and to see what progress had been made meeting any requirements from the last inspection. Also to check how the home was managing the introduction of dementia care since the last inspection. Information to support the findings in this report was obtained by looking at the pre inspection questionnaire (PIQ). Examples of information gained from this document include details of policies and procedures in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Records in the home were looked at such as care plans, medication records, policies and procedures, and complaints and accidents records. Some residents were spoken to as well as one relative and most members of staff on duty. A doctor who was seeing a resident was also spoken with. The home’s manager assisted throughout the day. CSCI comment cards and post-paid envelopes were left at the home to be given to residents and their relatives as well as comment cards for health care professionals who visit the home. At the time of writing this report one has been received. From the information in the pre inspection information provided by the home, the standard weekly fees range from £390 to £430. Hairdressing, private chiropody and newspapers and magazines are not included in the fees. From the evidence gathered at this inspection, the quality rating remains good. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the home has been in a position to move forward with the building. Two bedrooms have been improved with the addition of en suite facilities. The programme to redecorate bedrooms, lounges, corridors and hallways is ongoing. The lounge chairs have been re covered and new commode chairs have been bought. Changes have been made to fire doors in line with the proposals to change the categories of residents accommodated. At the time of inspection contractors were doing some retiling of the part of the roof that should cure a damp problem on the top floor. Redecoration of this area will follow. The kitchen has a new oven and an extractor hood. There have been new carpets and floor coverings throughout most of the building. There was one requirement made in the last inspection report that was about getting radiators guarded. A lot of this work has been completed. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 7 An activity organiser has been appointed and staffing levels have increased to take account of the dementia care now offered at the home. The home continues with an excellent training programme and exceeds the numbers of staff who should have a National Vocational Qualification. The manager will complete The Certificate in Dementia Studies during 2007. It is her intention to then move straight on in September 2007 to take a higher qualification at Bradford University in The Diploma in Dementia Studies. 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 Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and/or their relatives have the information that is needed before they choose a home. Assessments are made before people move in to the home, that give staff a clear idea of the person and their care needs. EVIDENCE: At the time of the last inspection the process of changing registration categories to include people with dementia had just been completed. Over the following months the home has admitted residents and at the time of this visit was providing care to fourteen people with dementia. A new statement of purpose that reflected changes in registration categories and the approach to this care accurately reflects the care and services provided at the home. Three care plans were checked to see that pre admission assessments were being made that would accurately provide information for a plan of care to be The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 10 drawn up. The home continues to be effective in getting up to date information in line with National Minimum Standards. Each file had detailed pre admission information that included local authority care plans and ‘easy care’ documents, discharge information from hospitals, and the homes pre admission documentation. The manager said that she encourages prospective residents and/or their families to make an introductory visit and was supported by comments made by a relative. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The healthcare needs of residents’ are met and care plans provide clear and detailed instruction for staff to follow. Staff are aware of residents’ needs and there is good communication amongst the staff group and with healthcare professionals. Medication policies, procedures and practices are good. Residents are treated with respect and in a dignified way. EVIDENCE: Three care plans were checked. These were specifically chosen for the specific care needs and one was the most recent admission to the home. The plans continue to be detailed and provide staff with clear information about the care needs of individual residents and guidance about the way to deliver the care. It was good to see life histories that included the residents childhood, working life, significant people in their lives, hobbies and interests, likes and dislikes, religious beliefs and significant life events. This gives the staff working with people a better understanding of the people they are working with. Care The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 12 needs had been accurately identified from the pre admission assessments and risk assessments were documented. The plans had been reviewed monthly or when care needs changed. In one case the residents nutritional needs had changed and there was clear and specific advice to staff on actions to be taken. Any liaison with healthcare professionals was well recorded, showing that there is regular contact with specialist services in relation to mental health and dementia where needed. A doctor who was visiting at the time of inspection was spoken with and said quite clearly that she had no concerns with the home, that staff demonstrate a clear understanding of the care needs of residents and that the home seeks medical advice at an early stage. She said that there was a good working relationship with the home. Three staff were spoken to individually and they had a clear understanding of their role, talked about the communication systems in the home like shift handovers and gave the clear impression that they were ‘on the ball’, knew each resident’s care needs and felt equipped through their training to deal with the challenges that come their way. The home has clear practices and procedures for storing, managing and administering medication. The pharmacist that the home deals with is involved in training staff. A focus was made on the medication for the three residents whose care plans were checked and it was good to be able to track in the care plan documentation where problems had been referred to the doctor, a diagnosis made, prescriptions requested and there was error free recording of the administration of the medication. Observations made throughout the day showed staff to be professional but personable with residents and relatives. The relationships were warm and friendly. Residents looked well cared for. Staff were seen to manage the residents sensitively and residents said that staff gave them good support, gave assistance when they needed it and respected their privacy like knocking bedroom doors before entering. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are positive about their lifestyles. Their social needs are assessed and documented and activities are arranged that are geared to stimulate and interest them. Residents are encouraged to make choices about what they do and enjoy contact with family, friends and visitors from the community. There is a balanced menu that residents like and any special dietary needs are catered for. EVIDENCE: Social needs are identified in the residents care plan and the useful life history, gives staff ideas about what to talk about, reminisce about and what interests and hobbies to aim at. The manager said that they aim to have activities each day and these include in house things like word quizzes, reminiscence, sensory activities, singing, music quizzes, bingo, cards, ball games and board games. An entertainer is booked to come in each month. The home has links with the local community and local amateur dramatic societies, nursery schools and the brownies visit the home periodically to give performance. There are also links The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 14 with local churches that provide a service in the home and communion for those who want to be involved. Activities are currently recorded on each resident’s daily notes. Positively, the home has just appointed an activities organiser whose specific role will be to develop the range of activities further. One relative was seen during the visit and spoken to privately. He said that he lived in the local community and the home had been suggested by the GP. He had looked at other care homes but felt comfortable with what he saw and was told at The Hollies and is now full of praise for the staff and the care provided. The relative said that his mother was always well presented. He had noticed that choice was available at meal times and felt this was good, indeed felt that mother was looking better and had put on weight since living at the home. He felt all of the staff are approachable keep him aware of any problems and felt comfortable that he could go to the manager at any time and that she had been supportive to the family. There was a general air of the staff doing things ‘above and beyond the call of duty’. The menus currently being used were sent with the pre inspection information and these show a good balanced diet. All meals provide a choice. The breakfast menu includes a cooked meal if wanted and some residents were finishing off cooked breakfasts at the start of the inspection. The lunch and tea time menus show good alternatives and there drinks and refreshments provided at supper time and throughout the day. Residents’ who were able, said that they enjoyed the food. Certainly the lunchtime meal was well presented and the special dietary needs were clearly dealt with. The residents were assisted with great care, sensitivity and encouragement. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relatives are aware of how to complain if they are unhappy with the standard of service, and this helps safeguard residents. Where they are able, residents are encouraged to express their views and with all residents, special note is taken of their non-verbal communication to determine if they are happy or unhappy with things. EVIDENCE: The pre inspection questionnaire confirmed that the home has a complaint’s and an adult protection procedure. The manager was fully aware of the adult protection procedure and how to report any allegations of abuse. Adult protection training has been provided for staff working at the home. The home has a complaint’s book to record any complaints and a copy of the procedure is on a notice board in the home and in the service user guide. The relative spoken with said that he felt comfortable in raising concerns but to date had not needed to. Throughout the day staff were seen to treat residents in a calm reassuring way. Staff were good at picking up non-verbal cues from residents and quick to give support. Residents have their own personal routines and preferred way of doing things like getting up and going to bed times or when they bath or The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 16 shower that are identified in their daily living plans. Staff were asked how they dealt with residents who had poor communication for example in choosing what clothes they wear each day. It was clear that they knew their residents well and their training in recognising the importance of non verbal communication had been beneficial in being aware when someone was pleased, liked or didn’t like what they were being shown or were doing. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained and offers comfortable communal lounge areas. Bedrooms suit personal needs, can be personalised with your own possessions and made private. The home has aids that make things like bathing and toileting easier. EVIDENCE: Since the last inspection the home has been in a position to move forward with the building. Two bedrooms have been improved with the addition of en suite facilities. The programme to redecorate bedrooms, lounges, corridors and hallways is ongoing. The lounge chairs have been re covered and new commode chairs have been bought. Changes have been made to fire doors in line with the proposals to change the categories of residents accommodated. At the time of inspection contractors were doing some retiling of the part of the The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 18 roof that should cure a damp problem on the top floor. Redecoration of this area will follow. The kitchen has a new oven and an extractor hood. There have been new carpets and floor coverings throughout most of the building. There was one requirement made in the last inspection report that was about getting radiators guarded. A lot of this work has been completed and the manager said that those radiators in the bathrooms that still have to be completed would be done in the New Year. All the communal areas and some bedrooms were seen. The bedrooms were personalised with residents’ personal belongings to make them more homely. No health and safety hazards were noted and staff were seen doing their work properly dressed and equipped, and their practices make sure the home is clean, hygienic and free from unpleasant smells. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The staff are experienced, well trained and know what they are doing. They have good relationships with the residents and care for them well. EVIDENCE: The pre inspection information provided copies of duty rotas that showed sufficient staff on duty. As part of the agreement for the introduction of dementia care staffing levels have been increased and it was good to see that staff are deployed to specific areas of the home so that as far as is possible, there is a member of staff available in each of the communal areas. Two of the newly appointed staff confirmed that they had gone through an induction training programme and there was documentary evidence to support this. They talked about more specialised training that has been programmed for them. There is a core of established and experienced staff who have worked at the home for a considerable time. They talked about training that they had been involved with and this covered key areas of safe working practice and National Vocational Qualifications (NVQ’s) as well as more specialised training like dementia and health care issues specific to the current resident group like diabetes. The pre inspection information shows that the home exceeds the The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 20 50 target that is set in National Minimum Standards for numbers of staff who should have an NVQ or equivalent. The company continues to employ a training coordinator whose role is to make sure that staff training is up to date and in line with the National Minimum Standards. This is commendable and a programme of the weekly training sessions that are provided came with the pre inspection information. There are well-established systems of communication and shift handovers to make sure that staff are up to date with any changes or specific needs and tasks. There is an established staff supervision system where staff have one to one sessions with the manager. The supervision agenda was provided with the pre inspection information and identifies specific issues for discussion with staff carrying out different roles. The personnel files for three newly appointed staff were checked and found to have all the required documentation. This shows that proper recruitment procedures are followed that make sure staff are properly checked and vetted before they take up appointment. Once again the staff spoken with demonstrated their professionalism, good knowledge of the residents they care for and their commitment to personal development and training. The home had conducted its own satisfaction survey in July and this probably accounted for the poor response to the CSCI survey. The home’s results showed the confidence and satisfaction that relatives and residents have in the manager and staff. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an open and friendly atmosphere created by good leadership and management. There is a clear approach to resident care that is person centred and puts the best interests of individual residents central to staff practice. Residents’ financial interests are safeguarded. Record keeping, safety checks and systems of communication make sure that the home is a safe place to live. EVIDENCE: The manager continues to checking and ‘on the job supervision system of the residents and the home’s The Hollies be ‘hands on’ to make sure there is personal supervision’, as well as the established formal staff team. The conversations with staff and satisfaction survey show a high regard and DS0000001462.V311791.R01.S.doc Version 5.2 Page 22 appreciation for her management style. The manager has completed the Registered Manager’s Award and will complete The Certificate in Dementia Studies during 2007. It is her intention to then move straight on in September 2007 to take a higher qualification at Bradford University in The Diploma in Dementia Studies. The home conducts an annual satisfaction survey that involves questionnaire surveys being sent to residents, relatives, staff and professional visitors. The last survey was carried out in July 2006. The results have yet to formulated into a report and it is recommended that this is done so that people completing questionnaires can see that their comments are taken seriously and the report is valuable to people who may be considering using the home. The completed questionnaires, sixteen from relatives and residents, were seen and some of the comments made were: • • • • • ‘I am comfortable and happy in the home and overall I think it is very well run’. My relative expressed that she enjoys living at the Hollies and likes the carers. She likes having the company and feels safe and comfortable’. ‘Overall I think this is a very well run home with good staff and provides as reasonably a happy atmosphere as possible’. ‘Well run and friendly’. A friendly and well-run home and I haven’t heard one complaint from my husband’. Likewise the ten surveys returned from staff were positive and in their conversations they talked about a ‘good team spirit’, ‘we are well managed and you feel able to say what you feel at staff meetings’ and ‘its good to have clear direction so that we know where we are’. There have been no changes in policies about holding cash for residents. Lockable facilities are provided in each bedroom so that individuals can keep their own cash and valuables. The home does not become involved in residents’ personal finances preferring this to be done personally by the residents, or by a relative or other representative like a solicitor. Any additional services that are received like hairdressing are invoiced monthly or paid for personally by the resident. The pre inspection information that was provided showed that the home checks facilities and equipment with the regularity it should. Regular health and safety checks are made by external agencies. Records of accidents are kept and monitored by the manager. The records for fire safety were checked and again, these were up to date and showed that equipment is checked and tested as it must be. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 23 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 3 X 3 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 23 Timescale for action All central heating radiators must 01/04/07 be low surface temperature or fitted with guards. Outstanding from report of 27/01/06. Good progress made and timescale for completion agreed. Requirement 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 OP33 Good Practice Recommendations The manager should complete a summary report of the results of the home quality assurance survey. The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 The Hollies DS0000001462.V311791.R01.S.doc Version 5.2 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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