Inspection on 26/09/06 for The Hollies

This inspection was carried out on 26th September 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hollies 22/02/06

The Hollies 19/09/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Hollies 9 Shirley Road Hanley Stoke on Trent Staffordshire ST1 3PF Lead Inspector Key Unannounced Inspection 26 September 2006 09:30 The Hollies DS0000064031.V308130.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 DS0000064031.V308130.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 DS0000064031.V308130.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 9 Shirley Road Hanley Stoke on Trent Staffordshire ST1 3PF 01782 205064 01782 269187 chris@delamcare.co.uk 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) Delam Care Ltd Mrs Monica Babski Care Home 18 Category(ies) of Learning disability (18), Mental disorder, registration, with number excluding learning disability or dementia (18), of places Physical disability (1) The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Physical Disability (PD) for named person only Date of last inspection 22nd February 2006 Brief Description of the Service: The Hollies is a Victorian property located in Hanley close to the local park and the college. It is close to recreational, leisure and shopping community facilities. It is close to a number of other homes owned by the same company and providing services to the same registration category. The home can offer long term care to 18 service users of both sexes that have a learning disability and/or mental disorder. The home offers accommodation on the ground and first floor. The home provides 16 single bedrooms and one double room. The home has two lounges and two dining rooms. The home has one bathroom upstairs and one bathroom with shower cubicle downstairs. The home has an attractive paved area at the rear that provides seating facilities. The current fees are from £285 – £610 per week. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a six and a half hour period. During the inspection many of the residents were spoken to individually and in small groups over lunch and in the lounge. These discussions looked at residents’ life within the home including how they spent their time, whether they had choices over their lifestyle and whether they liked living at the home. Discussions were held with three staff during the inspection to look at their knowledge and training and whether they were able to meet the needs of the residents. A number of residents’ bedrooms and all the communal areas were looked at including the kitchen, laundry and bathrooms. The inspection included examining a sample of resident support plans and looking at the arrangements for the administration of medication and for looking after residents’ money. Other areas looked at were health and safety practices including the arrangements for fire safety. Prior to the inspection a survey of residents, relatives and professionals was made. The home’s Care Manager has been promoted within the company and the process of recruiting a replacement is taking place. Until a replacement is recruited the manager will continue working at the home on a part time basis. The home had addressed the requirement and recommendations made at the last inspection. What the service does well: The residents said they liked living at the home. Comments included: ‘I like it here’ ‘Good things are going on holiday, shopping and days’ out’, ‘Nice place, nice people’ and ‘I visited and I decided I wanted to come’. The admission procedure included an assessment and a programme of visits to the home whereby residents could meet the staff and residents before deciding if they wanted to live at the home. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 6 Residents said they had plenty of things to do. A number were starting college, some went to mental health drop in centres where they played pool and could use the computers and one resident said that he went to the gym several times a week. Other activities included going to a local pub, the theatre, trips out and going on holiday. In the home there was a schedule of activities including baking, beauty evening, bingo and craft sessions. Residents took part in a number of household activities including keeping their bedroom clean and tidy, food shopping, meal preparation, laying and clearing the table and washing up. Residents were consulted over aspects of the running of the home and over activities they wanted to do. Staff consulted with residents both individually to ascertain their views over living at the home and through weekly resident meetings. Residents’ had their health needs met. They attended the GP, the optician, dentist and the chiropodist. A number were supported to attend for psychiatric appointments. The home was monitoring the weight of residents and took action of residents showed significant weight gain or weight loss. The home was addressing the needs of older residents both in respect of their health and personal care needs and in social and leisure needs. What has improved since the last inspection? What they could do better: The home needed to make sure that all risk assessments were clear and that assessments relating to medication identified the assessment process. The home also needed to complete its evacuation plan to ensure that this was in place should an evacuation of the home be needed. The carpet in the second dinning room was badly stained and need to be cleaned or replaced. The personnel files did not all contain a recent photograph of staff members and this needed to be addressed. It was also recommended that the home look at having more information in formats suitable for the residents and to look at further ways they can take part in running the home. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 7 The residents would also benefit from having another shower in the home. 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 DS0000064031.V308130.R01.S.doc Version 5.2 Page 8 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 DS0000064031.V308130.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure ensured that residents’ needs were assessed and that residents were able to visit the home to making a decision over whether they wanted to move to the home. EVIDENCE: The home had admitted two residents during the last year and the files showed that the assessments had taken place to identify their needs. Assessments were completed by the local authority and health services and by the home. The assessments included health and personal care, leisure and social needs , spiritual, educational and domestic issues. Discussions with a resident confirmed that they were fully involved in the assessment and admission process. They stated that they visited the home a number of times and stayed overnight. She commented ‘ I decided I wanted to come’. Another resident reported in the pre inspection survey that they were involved in the admission process and were provided with information about the home. Placements were made on a trial basis being confirmed following a review involving the resident, the home and significant others. The Hollies DS0000064031.V308130.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s support planning process was identifying the needs of the residents and the home was in the process of working with residents to develop person centred plans. The home had a range of individual risk assessments in place although issues relating to one resident needed to be clarified. Residents were provided with choices over their lifestyle and had opportunities to participate in a number of tasks associated with running the home. EVIDENCE: Sampling showed that the home had developed individual support plans for the residents. These covered the areas of health and personal care, leisure and domestic needs as well as educational and needs associated with managing money. Records and discussions with residents confirmed that plans were reviewed internally on a six monthly basis. Those residents on the Care Programme Approach had a multi disciplinary review. The home had developed individual risk assessments covering such areas as managing hot water, accessing the community and use of the kitchen. The home had completed fire risk assessments for the residents. These were up to The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 11 date and had been reviewed. There were some areas of risk relating to one resident that was not clearly identified and a risk assessment relating to selfmedicating did not specify the assessment process that took place. These were raised with the senior staff member on duty. Residents confirmed that they were provided with choice and supported to make decisions over their lives. They said that they were able to have their breakfast when they got up and to choose what they wanted from a range of food. The said that they could take part in activities of they wanted. Residents chose when to go to bed. They could choose whether to spend time in their bedroom or in any of the communal rooms. During the inspection residents were seen freely accessing the communal rooms and bedrooms. Residents were observed being provided with choice over such issues as how they wanted to spend their time, whether they wanted to go shopping and over meal choices. Discussions with residents and examination of records showed that there were resident meetings held every week. Residents said that they talked about activities they wanted to do, menus and any concerns they had. Residents were involved in a range of activities relating to the running of the home. Many were supported to keep their bedroom clean and tidy. Some helped staff with meal preparation and doing the food shopping. Residents were observed laying and clearing the table and washing up. There was scope for further resident participation in such areas as policy development and staff recruitment. The Hollies DS0000064031.V308130.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to access a range of social, educational and leisure activities and regularly access community resources. The home provides residents with meals that they like and that takes account of their choices. EVIDENCE: The home has a good record in supporting residents to access educational opportunities. However at the current time college courses have not commenced and the activity staff member was supporting residents to identify courses or alternatives activities for those that wished to take part in educational opportunities. Talking to residents confirmed that many had previously attended courses including painting and decorating, gardening, art and drama and jewellery making. Several residents had certificates of their educational achievements on their bedroom walls. A number of residents were taking part in a drama group and others were taking part in a gardening project. Three of the residents had some emplyment and received therapeutic earnings. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 13 Most of the residents regularly accessed the community either independently or with other residents. Comments included: ‘I go into town to buy my clothes’ and ‘I go to the bank’. The staff provided support to those that needed it to access the community. Examination of files showed residents accessing community health resources, going to the bank and shopping including one resident who was supported to go to the Methodist bookshop. Residents had the opportunity to access leisure and social activities both in and out of the home. Discussions with residents showed that activities included attending the Dolphins club, going to the pub, the theatre, shopping and day trips out. One residents said ‘I like it here. I go to the Dolphins, to the pub and to the theatre’. Several residents went to mental health drop in centres where they could play pool, use computers and have refreshments. One resident said she enjoyed going to have an Indian Head Massage and another said that he went to the gym four days a week. Residents and records confirmed that the staff organised a range of activities in the home. One resident stated ‘at night we can do cooking, games, bingo and karaoke’ and another resident said that she enjoyed knitting. The home took account of the older residents when looking at appropriate activities. The home organised a number of holidays that the residents paid for. These were well liked, with residents commenting how they had enjoyed them. Holidays this year had included some residents going to Wales and a group going to Turkey. The staff took account of residents’ needs and wishes organising holidays suitable for those with mobility needs and those that wished a more relaxed holiday. All the residents had bus passes and had the use of people carriers. Residents paid for the use of the home’s transport. The home’s routines were quite flexible taking account of the number of residents living at the home. Times for getting up and going to bed were flexible based on residents’ wishes. Residents were observed freely accessing all the communal rooms and their bedrooms. Meals tended to be taken at regular times but residents could eat in their bedrooms if they wished. Residents said that their privacy was respected and observation showed staff knocking on doors and waiting to be invited into the room. All bedrooms were lockable allowing residents to have privacy. The home allowed residents to keep small animals such as birds but this would need to be discussed with staff first and it was the resident’s responsibility to look after a pet and pay for any costs. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 14 Residents confirmed that visitors could visit them and several residents had visitors from nearby care homes. A relative that responded to the preinspection survey stated that they were made welcome by staff. Meals were varied and provided residents with choice. Breakfast was cereals and toast and residents could have this went they got up. Lunch was of a snack type and on the day of the inspection it was pasty and beans or sandwiches or salad followed by fruit. The main meal was in the early evening and was for example meat or fish with vegetables followed by a sweet. On Sunday the main meal was at lunchtime and was always a full Sunday lunch. The menu did not offer a choice but all the residents spoken to said they could have an alternative if they did not want the meal identified. Residents said they liked the food. Comments included: ‘ I like the food’ ‘I tell them if I don’t like a meal and I can have something else’, ‘There is always salad available’ and ‘There is always fruit’. The home monitored the weight of residents and supported residents to have a healthy diet, encouraging residents to seek medical advice with weight issues. One resident who was trying to loose weight said that staff were supporting her to do this. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents were being met with evidence of multi agency working taking place. The home’s arrangements for administrating medication was meeting the residents needs. EVIDENCE: The support plans identified the health and personal care needs of the residents. Discussions with staff showed them to be fully aware of the individual needs of the needs and how these were to be met. Most of the residents needed prompting to undertake personal care tasks and residents said that the staff provided them with this support. A few residents needed practical support and an examination of records and discussions with one resident confirmed this was being provided. Observation showed that hair and nail care was being addressed. Residents said that they could have a bath or shower when they wanted. Discussions with residents and staff confirmed that the home was meeting the health care needs of the residents. Residents stated that they saw the GP when they felt ill, visited the dentist, the optician and some saw the chiropodist. Residents also received psychiatric services seeing psychiatrists and Community Psychiatric Nurses. Several residents had diabetes and the The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 16 home supported them to attend a local diabetic clinic. The home regularly weighed residents and supported any residents with weight issues to seek medical advice. The home had links with the continence nurse and had received training in catheter care. The home’s arrangements for the administration of medication were inspected. The home kept medication securely in locked cupboards. The home kept comprehensive records of medication including a description and the effects of the medication. The home maintained records of the medication that was delivered to the home and of any returned to the pharmacy. Most of the residents were on a monitored dosage system. A sample of residents’ medication was inspected. These showed that medication records were being completed correctly and there were no gaps in the records. The home had PRN protocols in place. One resident spoken to said that she was having a review of her medication. One resident was self-medicating and an assessment had been completed although the nature of the assessment was not clear (see standard 9). The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a complaints procedure and residents felt listened to however it would be beneficial for the procedure to be in a more user-friendly format. The home had a procedure for safeguarding residents and staff were aware of the actions to be taken if they had any concerns. EVIDENCE: The home had a complaints procedure and this was displayed in the hallway although it was not in a user-friendly format. The home maintained a record of complaints. The home had received one complaint and this was responded to promptly to the satisfaction of the complainant. Residents spoken to were aware of how they could raise issues identifying the resident meetings and talking to staff. Discussions with residents showed that felt that the staff listened to them and one commented ‘ staff listen and try and sort out our problems’. The home had a procedure for responding to incidents of adult protection. Staff spoken to were able to state how they would respond if they suspected abuse. The company provided staff with training in this area and had plans for a staff member to undertake training to be able to train the staff in this area of the work. The home had procedures to safeguard residents’ finances. Examination of a sample of records showed that suitable records were being kept and that residents were involved in decisions about their finances. All residents had a bank account. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 18 Discussions with staff showed that some residents exhibited some difficult behaviour. The home does not use physical restraint and the company provided training in non-violent crisis intervention techniques to respond appropriately to any incidents. It would be beneficial if all staff had this training. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided residents with suitable accommodation. Bedrooms were well personalised and provided residents with privacy. The home provided adequate toilet and bathing facilities but residents would benefit from additional shower facilities. Residents were provided with accommodation that was clean and hygienic. EVIDENCE: The home was located close to Hanley Park and within a 20minute walk from the centre of Hanley. The home was satisfactorily maintained and decorated throughout in a domestic style. Externally it has a rear yard with plants and garden ornaments and seating for the residents. The home provided adequate accommodation for the residents. All except one bedroom was for single occupancy and five single bedrooms and the one double room had ensuite facilities. Bedrooms were suitable for the occupants having adequate storage facilities. Both residents in the shared room were spoken to and they said they liked sharing and had done so for a number of years. The bedroom was large and had a seating area with TV at one end. Bedrooms were lockable and all those seen were well personalised. Residents had made their bedrooms homely with lots of their own possessions. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 20 Some bedrooms had facilities for making drinks and a few had their own fridge. The home had adequate toilet and bathing facilities. Downstairs there were two toilets and a bathroom with bath and a separate shower cubicle and toilet. Upstairs there were three toilets and a bathroom with bath and toilet. Residents would benefit from additional shower facilities. The home had two lounges, one of which had a TV, video and DVD. The other was for quiet activities and for meetings. Both rooms were homely and decorated in a domestic manner. There were two dining rooms. One was also used for activities such as craft and artwork. The home had a large domestic kitchen that was large enough for staff and residents to work together in. The home had a small laundry. The home was clean and tidy and the home had procedures in place to control the risk of infection. The Hollies DS0000064031.V308130.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided staffing levels that were adequate to meet the needs of the residents. Training was providing staff with the necessary knowledge and skills but there was scope for increased levels of training for some staff and a need for more staff to be qualified to at least NVQ level 2. The recruitment and selection process was safeguarding the residents although this would be improved through ensuring that all files contained recent staff photographs. EVIDENCE: Examination of the rosters showed that the home’s staffing levels were adequate. There was a minimum of three staff on duty in the morning and a minimum of two on duty in the afternoons although on most occasions there were three on duty. There was always a senior support worker or a manager on duty. The Care Manager and the activity staff member were on duty in addition to the care staff. The activity staff member was employed on a fulltime basis and his hours were flexible to meet the needs of the residents working some evenings to support residents to attend the Dolphins club and to go to the pub. The home had two walking night staff. The home currently had vacancies for additional activity hours and a housekeeper. The home maintained suitable records relating to staff training. This showed that the home had six staff qualified to at least NVQ level 2 and a further six The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 22 were enrolled on the qualification. Several were waiting to take NVQ level 3. In addition three staff had undertaken LDAFF training specifically designed to for people working with people with a learning disability and another two were doing the course. Additional training included non-violent crisis intervention, adult protection, medication and mental health awareness although not all staff had undertaken these. A sample of staff personnel files were examined. These showed that the home was undertaking the necessary pre employment checks including CRB and POV and obtaining two references. The home was confirming applicants’ identity. Not all files had a recent photo on them although the home had plans to address this. The company held copies of prospective staff’s health checks. Staff were provided with a contract outlining their terms and conditions. The Hollies DS0000064031.V308130.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well run and although the current manager is due to leave, the home has put in place suitable interim arrangements and the necessary procedures to ensure that the position is filled quickly. The home undertakes a range of procedures to review and monitor the quality of the service which include the views of residents The health and safety procedures are generally safeguarding the residents but the home does need to complete and implement the evacuation procedure. EVIDENCE: The manager who has worked at the home is due to leave in the near future having obtained another position within the company. She is currently working part time until a replacement is in place. The recruitment process is well under way and a new manager should be in place in the near future. Under the current manager the home has been well managed. The home has a number of systems in place to review and monitor the service provided to the residents. These include some residents’ surveys and regular The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 24 monitoring of care practices such as medication and consultant reviews, 1:1 key worker sessions and support plan reviews. There continues to be scope for further development such as gaining the views of relatives and professionals. The home had health and safety procedures in place. Sampling of Health and Safety records confirmed that the home was undertaking the required fire checks including the fire alarm and emergency lighting and doors. The home was having regular fire drills. The home had a valid electrical installation check and a gas safety certificate. The home had developed fire risk assessments and was in the process of developing an evacuation plan. The home was undertaking weekly checks on the temperature of water. The temperatures of freezers and fridges were checked regularly. The staff had undertaken the necessary health and safety training and the home had plans in place to ensure these were kept up to date. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(c) Requirement To ensure that the risk assessment discussed is clearly in file and that medication risk assessments include the process of assessment. To clean or replace the carpet in the second dining room. To ensure that all staff files contain a recent photograph To develop an evacuation plan. Timescale for action 01/11/06 2. 3. 4. YA24 YA34 YA42 23(2) 19 Schedule 2 23(4) (c)(iii) 01/12/06 09/11/06 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4. Refer to Standard YA6 YA8 YA6 & YA22 YA27 Good Practice Recommendations To undertake reviews including the resident and significant others To look at areas where residents could be more involved in aspects of running the home e.g. staff recruitment To develop further documentation including the complaints procedure in user friendly formats Consideration be given to provide additional shower DS0000064031.V308130.R01.S.doc Version 5.2 Page 27 The Hollies 5 YA32 facilities. For staff to receive training in working with people with challenging behaviour and in working with older people. The Hollies DS0000064031.V308130.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 DS0000064031.V308130.R01.S.doc Version 5.2 Page 29 - 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!