Inspection on 26/02/07 for The Hollies

This inspection was carried out on 26th February 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hollies 22/05/07

The Hollies 17/10/05

The Hollies 27/06/05

The Hollies 17/12/04

The Hollies 01/05/04

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Thorndene

Insight - Eastchurch

Southfields

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Seabourne House

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Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 The Hollies 84 Barnham Road Barnham Chichester West Sussex PO22 0ES Lead Inspector Mrs M McCourt Unannounced Inspection 26th February 2007 09:00 The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 84 Barnham Road Barnham Chichester West Sussex PO22 0ES 01243 555230 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) None United Response Mr David Kim Oaten-Wareham Care Home 14 Category(ies) of Learning disability (14) registration, with number of places The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 14 male and/or female service users in the category of learning disability (LD) may be accommodated. Up to 8 service users may be accomodated in the main house Up to 6 service users may be accomodated in the bungalow. Only service users between the ages of 18 and 65 may be admitted Date of last inspection 17th October 2005 Brief Description of the Service: The Hollies is a care home registered for up to fourteen service users in the category of learning disability between 18 and 65 years. The registered provider is United Response, for whom the Responsible Individual is Mr T Jones. The registered manager is Mr D Oaten-Wareham. The current scale of weekly charge is £704 to £720 per week. This information was received from the registered manager. Additional charges are made for personal items. The Hollies is a detached property, with accommodation provided between the main house, consisting of eight bedrooms across two floors and an attached bungalow, that accommodates six Service Users. All areas are accessible to service users via a passenger lift if necessary. Some of the bathrooms are specially adapted for people with a disability and everyone has their own room. In addition there are extensive grounds that can be easily accessed by the residents. The home is located in a residential area of Barnham, with easy access to nearby bus and train services. The Service Users Guide and Statement of Purpose can be located at the home, and are accessible to Service Users, staff, relatives and anyone else interested in the service. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Monday 26th February 2007, and lasted a total of nine and a half hours. Pre-inspection planning took approximately two days. Preparation for the inspection included review of information, the request and examination of a Pre-Inspection Questionnaire, reading of various policies and procedures, including; admissions/referral procedures, staffing rotas, menus, complaints policy and any complaints received by the Commission for Social Care Inspection. A full tour of the building took place and included the observation of Health and Safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Five staff members, were spoken to at the time of inspection. Case tracking was carried out by examination of relevant records and information held on the staff and residents. The Inspector also spoke with six Service Users accommodated at the home. Policies and procedures were examined during the site visit. What the service does well: The home provides Service Users with the opportunity to exercise choice over decisions affecting their wellbeing. Resident meetings are held on a regular basis and are well attended. In addition, each Service User is allocated a key worker, responsible for monitoring their needs. The staff team is offered a wide range of training, in order to obtain the skills necessary to work effectively with Service Users. One staff member was seen communication with someone using Makaton and further observations by the Inspector found that staff were interacting with the Service Users appropriately at all times, despite some particularly challenging situations. The home responds promptly to complaints made by Service Users. There are comprehensive policies in place, using a step-by-step approach to dealing with comments, concerns and complaints. In addition the complaints procedure is written in Picture-book format, which is suitable for the client group. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 6 Quality assurance is in place, with the home using a number of different systems to obtain the views of Service Users and their relatives. A ‘Parents Forum’ meets every four months to discuss issues around supported living in preparation of when some of the Service Users transfer to this care setting. In addition, a newsletter is published by the home every three months, and this updates relatives on issues and events affecting the home. 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. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users’ needs must be assessed prior to admission and records retained. A written and signed contract, detailing terms and conditions between the home and the service user must be in place. EVIDENCE: On the day of inspection, assessment of need documents were not found in those files looked at. This is probably due to the fact that the Service Users were admitted sometime ago. For this reason it was difficult to evaluate if care plans reflect assessment of need. A sample of care plans looked at found them to be incomplete and out of date, with some plans not having been reviewed for eighteen months. The Inspector looked at one contract (called Individual Charter) and found it to be out of date and not signed by either the Service User, a representative or The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 9 the Registered Manager. In addition, two further files sampled did not contain any form of a contract between the service and the individuals. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The changing needs and personal goals of Service Users are not reflected in individual care plans. Personal care plans are out-of-date and incomplete in some cases. Service Users are encouraged to make decisions about their daily lives with support from the staff team. EVIDENCE: There was no evidence of Service Users involvement in drawing up their own care plans, and as previously highlighted, plans are not reviewed on a regular basis. The Registered Manager confirmed that the home does not hold review meetings and said that he was unaware that the home was responsible for holding them. Although a personal planning book was in place, it had not The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 11 been filled in completely. The goals section, which was not dated, had not been followed up. If it had been, it was not documented. A Key worker responsibilities policy states that staff are to meet with their key-client once a month, review their care packages and record the outcomes in their individual care plans. It also states that a yearly care review must take place. This is clearly not happening for the Service Users living at the home. Risk assessments are carried out for individuals and these were comprehensive in detail. However, risks are not reviewed as regularly as the home’s own policy states. In addition, the risk assessments folder for the part of the service known as No. 84 was being kept on top of the dining room dressing table, accessible by anyone. Many of the risk assessments pertinent to individuals contained very personal and confidential information. The Inspector was told that Service Users are given the opportunity to participate in the recruitment process, and a couple of Service Users are regularly involved in staff training. Three Service Users have accessed advocacy services recently via a local West Sussex group. The Registered Manager said that advocacy services are scarce in West Sussex and people have to go on a waiting list to access services. Service Users attend regular resident meetings. The Inspector spoke with one Service User who confirmed that meetings usually take place at the weekend. She told the inspector that menus for the forthcoming week are discussed, with each Service User putting forward a meal suggestion. The Inspector looked at minutes of Service User’s meetings, which are held on a regular basis. The Inspector noted that there is currently no follow up system, for when issues or requests are raised. The Registered Manager agreed to take this on board and implement a system for ensuring issues are picked up by the staff team. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are able to take part in age, peer and culturally appropriate activities within the local community. Personal relationships are recognised and supported by staff. Service Users are offered a healthy diet. EVIDENCE: Many of the Service Users attend college placements throughout the week. Activity rotas for Service Users were lacking in variety for some individuals. For example, according to the rota, one Service User spends most days ‘relaxing’ or ‘watching TV’. These two activities were written for 7 days each The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 13 afternoon, with only two or three morning trips out for food shopping or to visit the bank. The Registered Manager said the individual used to work but now does not wish to go anymore. He is however involved in staff training, and this he enjoys very much. Visual presence within the community is high due to Service Users travelling independently around the local area, to shops and leisure services. The staff team is trained in various subjects to obtain the skills necessary to work effectively with Service Users. One staff member was seen communication with someone using Makaton. Observations by the Inspector found that staff were interacting with the Service Users appropriately at all times, despite some particularly challenging situations. Menus are written up weekly, incorporating individual choice. Meals are then cooked by Service Users with support from staff. One Service User spoken with confirmed that the meals are okay “most of the time.” The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home endeavours to meet physical and emotional needs, although paperwork should be improved to ensure health issues are appropriately monitored and reviewed. Medication is retained in individual rooms and those looked at were appropriately stored and records accurate. EVIDENCE: Medical appointments are made and Service Users supported to attend, however they are not well documented. Appointment outcomes are often hand written on to scraps of paper and not well organised within personal files. This makes information difficult to find and there are gaps in consistency of information. Monitoring of specific conditions and health issues, such as epilepsy, does take place, however, the Inspector found one example of where a health issue had not been monitored or reviewed appropriately. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 15 Medication is stored securely in individual rooms, in metal, lockable cabinets that are fixed to the wall. Service Users are risk assessed as to whether they can hold the keys for their medication cabinets. The Inspector examined three sets of MAR sheets and the contents of medication cabinets. All written records were accurate and up-to-date. Medication storage was also accurate. The Inspector did however note that there had been at least five medication incidents recorded during January and February this year. The Registered Manager told the Inspector that the situation had been identified as a problem, and he intends to address it with the staff team. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users understand how to complain and their views are listened to and acted on. The home’s policies and procedures regarding adult abuse are comprehensive. EVIDENCE: There are comprehensive policies in place, using a step-by-step approach to dealing with comments, concerns and complaints. In addition the complaints procedure is written in Picture-book format, which is suitable for the client group. Service Users complaint forms were seen. Seven complaints have been recorded since the last inspection, and some of these had been written out by the Service Users themselves. All of the complaints had been investigated by the home and substantiated. Outcomes are written on the relevant form. A copy of the West Sussex County Council Adult Protection procedures is available at the home. The home’s own AP procedure, called Prevention of Harm, includes information on; POVA, No Secrets, Self-Harm and Suicide. The The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 17 majority of staff are have attended Adult Abuse training and are aware of their responsibilities. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home would benefit from a thorough clean throughout. All maintenance and redecoration issues should be prioritised on to a renewal and maintenance programme. EVIDENCE: The Hollies, although registered as one service, actually consists of one house and one bungalow linked together. They are run separately by staff and are referred to as “Hollies” or “84” in order to differentiate between the two. The Inspector conducted a tour of the buildings, which included bedrooms, communal areas and designated staff offices. Individual rooms are decorated to suit individual taste. The Inspector looked at several bedrooms, with one Service User explaining how she had chosen the colour scheme of her room. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 19 Several areas around the home are in need of redecoration. For example, the hallway carpet in Hollies is very badly stained generally, but especially around the kitchen and toilet area. On discussion with the Registered Manager, the Inspector was told that replacement of the carpet was not a priority due to budgetary constraints. It was also noted that a strip of tape is used to hold the edges of the carpet down in the hallway leading towards the front door. The Inspector found an incident report describing how a Service User had tripped over it. The kitchen/diner, although improvement work had been carried out, was still shabby and dirty in many areas, including several cobwebs with spiders and dead insects in them. The Inspector saw dirty windowsills, very dirty corners on both the floor (around the dishwasher) and work surfaces. The Registered Manager said that Service Users are supported to clean the house, but agreed, once pointed out, that some areas did look unclean. Paintwork was dirty and one area by the door leading into the garden had been re-plastered, but not painted over, making it look tatty. In the toilet/shower room next to kitchen there was a very strong, foul smell, that the Registered Manager said they were currently investigating, but as yet, to no avail. A Service User complained directly to the Inspector about the smell in the toilet. He said it “smells disgusting in there (pointing directly at the toilet) and it has been like that for several days”. There were several strips of cellotape keeping the boiler room door closed. COSHH products were found in another cupboard, and despite having a lock on the door, it had been left open. The Registered Manager was reminded that the home is providing a service, and as such, it was the home’s duty to ensure Service Users are protected from harm, including risks from harm. Beside the toilet there were several tiles that were coming away from the wall. The Registered Manager said that this was due to the investigative work being carried out. The Inspector looked at four bedrooms further down the hallway. Whilst individual in layout, they also looked tired and worn. Outside one of the bedrooms there was a patch of repair work, that again, had not been repainted. The dining room in 84 also looked tired and grubby in places, especially the windowsills that were heavily stained from cups. Corners and paintwork areas also need attention. In this room the Inspector found a risk assessments file, containing a number of private and confidential information, on top of the The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 20 dresser. It remained there throughout the course of the inspection and was accessible to anyone. In the kitchen, despite there being two soap dispensers next to the hand basin, neither of them had any soap in. There were no hand towels either. Three COSHH products had been left around the basin area. The fridges contained food that was out of date. Labelling of food was poor, with ketchup, ham slices, margarine, soft cheese and chicken paste, etc all opened but with no labels on. Some of these products needed to be consumed within three days of opening (chicken paste, cheese, etc) and the sauces within four weeks, but there was no way of knowing when this would be. The lounge was bright, spacious and nicely decorated. Four Service Users bedrooms were looked at and were found to be in a better condition than those in the Hollies. One of the Service Users allowed the Inspector into her room and explained how she had chosen the colour scheme, for her room and really liked it. Service Users benefit from spacious garden areas to both properties, with one of the Service Users designated his own ‘patch’ of garden, where he likes to grow vegetables and plants. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are supported by competent and qualified staff team, with a good level of training offered. Records show that Service Users are supported and protected by the home’s recruitment procedures. Staff members would benefit from regular supervision sessions. EVIDENCE: The Registered Manager is an NVQ assessor and explained to the Inspector that all staff employed at the Hollies start at level 3. However, only two staff have achieved NVQ, although six are in the process of completing the qualification. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 22 Staff meetings take place on a regular basis, approximately one each month and minutes of the meetings were available for inspection. Recruitments records were examined, with the Inspector sampling three sets of files. All of those looked at contained the relevant information required to ensure the protection of Service Users. Training and development records show that staff have access to a wide range of courses, including mandatory subjects and training specific to their role. Staff spoken with confirmed that they do receive regular training and are able to request courses. Supervision policies and procedures are in place, although records show that not all supervision sessions take place as regularly as indicated. For one staff member there was only one recorded supervision session, although the manager said that he thought there had been more, but that the notes were stored elsewhere. Staff spoken with confirmed that supervision was ‘hit & miss’. The Inspector noted that during observations of interaction with Service Users, the staff were seen to responded sensitively and appropriately at all times, at times dealing with some very challenging situations. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality assurance systems are in place. There are some Health & Safety issues that must be addressed to ensure that the health, safety and welfare of Service Users and staff are fully protected. The Registered Manager must ensure that Regulation 37 incidents are forwarded to the Commission. EVIDENCE: The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 24 The Registered Manager, Mr Dave Oaten-Wareham has managed the service since 2002, when he was registered with the National Care Standards. He currently has NVQ 4 and is in the process of obtaining his RMA. He already has an NEBS management diploma and only needs to complete two units in order to be awarded the RMA. His own development includes learning more about domiciliary care and supported living standards, in order to prepare for when Service Users from the Hollies transfer to a supported living setting. He has also recently attended food hygiene, quality assurance and quality and diversity training. He is due to attend disciplinary and sickness training. Quality assurance questionnaires are sent to Service Users annually from head office. Regulation 26 visits are carried out and these form part of the overall monitoring process. The Registered Manager said that a ‘Parents Forum’ meets every four months to discuss issues around supported living, in preparation of when some of the Service Users transfer to this care setting. In addition a newsletter is published by the home every three months, and this updates relatives on issues and events affecting the home. Mandatory training is provided for all staff. Health & Safety policies and procedures are in place. The Inspector reminded the Registered Manager that confidential information must be stored securely, particularly risk assessments of a personal nature. In addition, identified risks are required to be monitored and reviewed regularly. As previously highlighted, COSHH products had been found around the home, in full view and accessible to Service Users. The staff team does not routinely complete records required to monitor health and safety matters, with issues arising around food hygiene and fire safety. Due to the nature of the service, there are a significantly high number of incidents and accidents recorded, including medication errors. The Inspector noted that there is no system in place for following up or reviewing how and why these incidents happen, and therefore how to reduce them, despite clear guidelines to do so. The Inspector also noted that many of the incidents have not been forwarded to the Commission for Social Care Inspection under Regulation 37. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 25 Fire records are kept and a contract is held with the Mercury Fire Alarm Company, who last visited on 6.2.07, the outcome being satisfactory. The fire warning system is tested weekly and drills were carried out, although not on a monthly basis, as is stated in the home’s own policy. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 1 3 x 4 x 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 x 27 3 28 3 29 x 30 2 STAFFING Standard No Score 31 3 32 2 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 x LIFESTYLES Standard No Score 11 2 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x 3 x 3 3 x 1 x The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 27 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement Full assessment of need must be carried out by the home prior to admission. The assessment must be kept under review and stored securely on individual files. All Service Users accommodated at the home must hold a standard form of contract for the provision of services and facilities provided by the registered provider to Service Users. (b) The premises to be used as the care home must be of sound construction and kept in a good state of repair externally and internally. (d) All parts of the care home are to be kept clean and reasonably decorated. All service users must have an up to date care plan that is reviewed on a regular basis, at least every six months, or more frequently if there are changing care needs. (a) All parts of the home, to which Service Users have access, are free from avoidable risk and DS0000014779.V326311.R01.S.doc Timescale for action 30/06/07 2. YA5 5(c) 30/06/07 3. YA24 23(2) 30/06/07 4. YA6 15 30/06/07 5. YA42 13(4) 30/04/07 The Hollies Version 5.2 Page 28 6. YA42 37(e) any harmful substances (COSHH products) must be secured appropriately within the home. The registered person must inform the Commission, without delay, of any event in the care home that adversely affects the well-being or safety of any Service User. 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA36 Good Practice Recommendations Staff would benefit from regular, recorded supervision meetings at least six times a year with their senior or manager, in addition to regular contact on day-to-day practice issues. The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 The Hollies DS0000014779.V326311.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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