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Inspection on 20/06/07 for The Hollies Nursing & Residential Home

Also see our care home review for The Hollies Nursing & Residential Home for more information

This inspection was carried out on 20th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

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

What the care home does well

What has improved since the last inspection?

The care plans seen had evidence that either the resident or their relative had been consulted about these. This meant that they could voice their opinion of how they were cared for. There was information in the care plans about the actions staff had to take to prevent pressure sores forming. This ensured that those residents identified as being at risk had the correct care. The policies and procedures for medications had been updated so that staff knew what to do when medications were no longer needed at the home. Staff were now signing and witnessing any handwritten additions to the Medication Administration Recording charts. This ensured that the details were accurate and residents received the right medication. All staff had received training in safeguarding adults. This meant that they knew what to do if they saw, heard or suspected something was not right. All staff had done a short training session on Dementia care. Some staff were also doing a more intense course on how to care for people with dementia. This would give them additional skills and knowledge of how to care for residents. Information was being sent to relatives in a newsletter. This enabled them to be kept up-to-date with what was happening at the home. The results of a survey done in 2006 had been sent out to all relatives in this newsletter so they knew how the home was performing. New audits had been started that looked at all aspects of the service provided at the home. This meant that the manager became aware of any shortcomings and could take action to resolve these.

What the care home could do better:

There should be a more thorough statement made about the outcomes for the month when the care plans are being reviewed. This would enable it to be seen if the actions being taken were meeting the needs or not. If a problem or need changes significantly then this should be rewritten so that staff have current directions on what to do. Where bedside rails are used in the best interests of residents there should be a regular maintenance programme that looks at all aspects of these. This would ensure that the rails were appropriate for the type of bed and continued to be safe for use. The discrepancy between the Controlled Drug register and the balance of medications in the cupboard must be investigated so that it can be assured that medicines are being given correctly. All bedroom doors should close fully so that there is no risk to the resident if there is a fire. Action should be taken to explore alternative floor covering in certain rooms where there is an odour so that the room remains pleasant to live in.

CARE HOMES FOR OLDER PEOPLE The Hollies Nursing & Residential Home Church Street Clayton-le-moors Accrington Lancashire BB5 5HT Lead Inspector Mrs Janet Proctor Unannounced Inspection 20th June 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies Nursing & Residential Home DS0000022498.V332694.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 Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Nursing & Residential Home Address Church Street Clayton-le-moors Accrington Lancashire BB5 5HT 01254 381519 01254 395477 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) The Hollies Nursing & Residential Home Limited Mrs Margaret Holden Care Home 42 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (32), of places Physical disability (2), Physical disability over 65 years of age (35) The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Within the overall total of 42 a max of 35 service users requiring nursing care who fall in the category of PD (E) Within the overall total of 42 a max of 32 service users requiring personal care of the category OP Within the overall total of 42 a maximum of 2 service users requiring personal care who fall into the category PD Within the overall total of 42 a max of 1 (One) named service user in the category of dementia, over 65 years DE(E) may be accommodated in the home. 2nd December 2005 Date of last inspection Brief Description of the Service: The Hollies provides 24 hour nursing and personal care for up to 42 people. The registered providers are The Hollies Nursing & Residential Home Ltd. The day-to day management of the home is undertaken by one of the registered persons and there is a Registered Nurse who takes responsibility for the care management of the residents. The home is situated in Clayton-Le-Moors close to local amenities including a park. The home is a large detached property with gardens, which are easily accessible to all service users. A parking area is available for use by visitors and staff. Accommodation is provided in single or twin-bedded rooms. There are no en-suite rooms but toilet and bathroom facilities are within easy reach of all rooms. A passenger and stair lift facilitates access to all areas of the home. Communal lounges and dining rooms are located on the ground floor. Information is available about the home in a Statement of Purpose and Service User’s Guide. In June 2007 the fees charged were £319-50 to £495-00 per week, depending on the level of care needed. Items not covered by the fee included: Hairdressing; Clothing; Private chiropody; Toiletries; Newspapers; and holidays. The Hollies Nursing & Residential Home DS0000022498.V332694.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, which included a visit to the home, was conducted at The Hollies on the 20th June 2007. No additional visits have been made since the previous inspection. On the day of the inspection there were 30 residents at the home. Prior to the visit the Registered Person had submitted information in a preinspection questionnaire. This gave information that was used in the planning of the inspection. Surveys were sent out and were returned by 10 residents and 9 relatives. On the day of the inspection information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to residents, the Manager, staff members and visitors. A tour of the building took place. Wherever possible the views of residents were obtained about their life at the home and their comments are included in the report. What the service does well: Staff at The Hollies ensured that residents had a thorough assessment of their needs before admission. This meant that their needs were known and arrangements could be made to ensure that these were met. A plan of care that identified the personal and health care needs of the resident was started as soon as possible. This gave staff directions on what to do to care for the resident so that the care would be given in the right way and in a consistent manner. Residents were provided with a range of activities. A resident said, “I like living here. The staff are very nice. We play dominoes and sometimes do bingo. There’s some very nice people here.” The relative surveys also made comment about the activities, “Tries to have different things going on to suit the different interests of residents” and “Plenty of activities that involve the residents.” There was a choice at mealtimes and residents were involved in deciding what was on the menu. All residents spoken to said that they enjoyed the food at the home. They said, “The food’s champion and there’s plenty of it” and “The food’s very good, I always enjoy my meals”. One of the relative surveys said, “Excellent food.” The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 6 All of the residents spoken to said that they had no complaints and they were happy at the home. A resident said, “I’ve been here just over a year. I’ve no complaints at all. The staff are very nice with me – they look after me very well.” In addition to the usual staff numbers there were extra on duty over the lunchtime and teatime period. This meant that all residents received enough attention during the mealtimes. The Registered Nurses also had an overlap of one hour so that they could give each other full information on resident’s conditions. The staff spoken to said, “There’s enough staff on duty to do what we have to” and “The staffing levels are good. The manager always makes sure that there’s enough of us on.” One of the relative surveys commented, “Always plenty of carers on duty”. The procedures for recruiting staff were thorough. This meant that staff were checked to ensure that they were right for the job. A high number of care staff had the National Vocational Qualification in care. This gave them the skills and competence to know how to care for residents. What has improved since the last inspection? The care plans seen had evidence that either the resident or their relative had been consulted about these. This meant that they could voice their opinion of how they were cared for. There was information in the care plans about the actions staff had to take to prevent pressure sores forming. This ensured that those residents identified as being at risk had the correct care. The policies and procedures for medications had been updated so that staff knew what to do when medications were no longer needed at the home. Staff were now signing and witnessing any handwritten additions to the Medication Administration Recording charts. This ensured that the details were accurate and residents received the right medication. All staff had received training in safeguarding adults. This meant that they knew what to do if they saw, heard or suspected something was not right. All staff had done a short training session on Dementia care. Some staff were also doing a more intense course on how to care for people with dementia. This would give them additional skills and knowledge of how to care for residents. Information was being sent to relatives in a newsletter. This enabled them to be kept up-to-date with what was happening at the home. The results of a survey done in 2006 had been sent out to all relatives in this newsletter so they knew how the home was performing. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 7 New audits had been started that looked at all aspects of the service provided at the home. This meant that the manager became aware of any shortcomings and could take action to resolve these. 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 Nursing & Residential Home DS0000022498.V332694.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 Nursing & Residential Home DS0000022498.V332694.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents received a full assessment prior to moving into The Hollies with the result that their needs were known and met. EVIDENCE: Three resident’s files were examined. There was evidence that a pre-admission assessment was done before the person came to live at The Hollies. This was very detailed. The Care Manager said that it was usual practice for her to visit and assess prospective residents before offering them a place at the home. At this time she tried to get as much information as possible so that there was a true picture of the person’s needs. Following the assessment prospective residents received a letter confirming that their needs could be met at the home. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 10 Four of the relatives surveys returned said that they felt that the home always met the needs of the resident and five said that they usually did. A resident said, “I’ve been here 2 weeks and I’ll be going home today or tomorrow. I’ve been here before –It’s very good here.” A relative said, “This place was recommended to us. It was the right decision, we’ve no regrets at all.” Intermediate care was not given at The Hollies. The Hollies Nursing & Residential Home DS0000022498.V332694.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. 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. Each resident had a plan of care so that their healthcare needs were identified and staff knew how to meet these. The medications were well managed and ensured that residents were safeguarded. EVIDENCE: The individual care plans of 3 residents were inspected. These identified the personal care needs of each resident. One plan for a recent admission showed that it had been written on the point of admission. The plans stated whether the resident needed prompting, assistance or full help and how many staff were required. Care plans were reviewed monthly. The reviews were not as thorough as they could be as they did not always give a statement of the progress that had been made during the month. Some problems/needs had changed entirely and this was not always apparent. For example a resident’s plan had a problem written The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 12 about her catheter. This had been removed over 12 months ago but the problem had not been rewritten to show how her continence needs were to be managed. There was now evidence in two of the plans seen that residents or their relatives had been involved in the care planning process. Eight of the relatives surveys returned said that they were always kept aware of important matters affecting their relative/friend and one said they usually were. Appropriate assessments for prevention of falls, prevention of pressure sores, nutrition, and moving and handling needs were undertaken. Directions were given to staff on how to meet these needs. Residents were registered with a GP of their choice and other professionals and specialists were contacted for advice when necessary. A number of residents used bedside rails. There was an assessment to show that these were in the best interests of the residents. All had bumpers. Discussion took place with the registered manager and the care manager about the need for a maintenance schedule that looked at the appropriateness of the rails for the bed and in particular about the size of any ‘gaps’. The care manager said that she had started a Key worker system. These were allocated to teams. A member of staff said that this seemed to be working well and she was happy with the system. All of the resident surveys returned said that they got the care and support and medical attention that they needed. Residents spoken to said that they got on well with the staff. A relative said, “They’ve been so good with mum and taken excellent care of her. They’ve kept us fully informed of everything that’s going on. They ring us when the Doctor’s been so we know what he’s said.” There were policies and procedures for all aspects of medication management. The procedure for the method of disposing of the medications had been changed to reflect current practice. There were records for all aspects of the process of medication management. The medications were stored in a separate, clean, room that locked. The temperature of this room was being recorded. This showed that it was remaining under 25 º C . There were adequate cupboards for the storage of the medications. There was little excess stock kept. There was a Controlled Drug cupboard and an appropriate register. On checking the medication in the Controlled Drug cupboard it was found that the balance of one of these was incorrect. No resident administered his or her own medication; the Registered Nurse on duty did this. Each resident had a Medication Administration Recording chart that listed their medicines, when they were to be given, and who had given The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 13 them. These were completed accurately. Handwritten additions to the MAR charts were now always signed and witnessed. Privacy and dignity were respected. Training on this was given to staff during Induction. Staff were seen to knock on doors before entering. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities were done and visitors made welcome, which resulted in the social and recreational needs of residents being met. Residents were provided with a balanced, nutritious diet that was to their liking. EVIDENCE: Residents spoken to said that they had a flexible life style to meet their diverse needs. They were able to make choices about what time they got up and went to bed. Staff spoken to confirmed this. Residents could use their rooms as and when they wished and could have their meals in the dining room or in their bedroom. Holy Communion was held at the home and residents had a choice of whether they wanted to join in this or not. A Bible reading class was held each week for those who wanted to join in. There was a programme of activities on display near to the notice boards. Special ‘theme’ days were arranged on occasion. Staff said that they did The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 15 activities each afternoon with the residents. Some residents spoken to said that they chose not be involved in activities and entertained themselves. Nine of the resident surveys returned said that there were always activities arranged that could take part in and one said there sometimes was. The relatives surveys also had positive comments about the activities available for residents. Visitors were welcome at the home. A newsletter had been started and this went out to all relatives every three months to keep them in touch with what was going on at the home. Comments from the relatives surveys included, “The news letter keeps me up to date with what’s happened/planned” and “everyone is kind and helpful whenever I or any other person visiting mum has need to approach a member of staff.” There was a menu on display for residents to look at. The items on this were discussed at residents’ meetings so that they could make suggestions about what should be on the menu. A hot meal option was served at every mealtime. Drinks were available at all times of the day. A supper was given out in the early evening and night staff had access to food to make snacks and drinks if anyone was hungry during the night. There was a sufficient amount of food in stock. This included fresh food. Records of food storage and cooking temperatures were kept. Each item at meal time was served individually to residents at the table. This meant they could have as much or as little as they wanted. Any pureed diets had their components done separately so that they looked more attractive and appetising. The staff gave discrete assistance to residents. Residents spoken to made positive comments about the food. Seven of the resident surveys returned said that they always liked the food at the home and three said they usually did. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents could be confident that their concerns would be listened to and acted upon. The procedures and staff training ensured that the residents were protected from harm. EVIDENCE: There was a complaint procedure and a recording system. No complaints had been made to the home. One concern had been referred to the home through the Commission. This was currently being dealt with. Residents spoken to said that they had no complaints and were happy at the home. All of the resident surveys returned said that they knew who to speak to if they were unhappy and that staff listened and acted upon what they said. There was evidence of this in one plan of care where a resident had expressed dislike with their room and action had been taken the next day. There was a Whistle blowing procedure and a procedure for staff to follow should they suspect or witness an incident of abuse. All staff had now done training in safeguarding adults. Staff spoken to at the time of the inspection were aware of what they should do if they saw, heard or suspected that something was not right. They were aware that they could go to outside Agencies with the information. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 17 The Care Manager was looking to obtain some training for staff on dealing with challenging behaviour so that staff would feel confident about what to do should such a situation arise. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 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 provided a safe, pleasant and comfortable environment for residents to live in. EVIDENCE: The home was clean and well maintained. One of the bedroom doors would not close properly and this might reduce safety if there was a fire. The decoration and furnishings were homely. Some areas and bedrooms had recently been redecorated. There was access to gardens that were attractive and well kept. Repairs were reported and action taken. Residents spoken to said, “The room’s Ok – the bed’s comfy and I sleep well” and “My husband and I have a double room and that’s nice, being together. It’s a nice large room.” The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 19 The home was clean at the time of the inspection. All of the resident surveys returned said that the home was fresh and clean. A resident said “They come in every day and keep my room clean”. There was an odour in some of the bedrooms. Discussion took place with the registered manager about the use of alternative floor covering for those rooms if continence could not be controlled. The systems for maintaining hygiene included procedures for infection control. Plastic aprons and gloves were available to staff when undertaking care duties. Liquid soap and paper hand towels were available in communal areas and in specific bedrooms. This helped prevent cross infection. There was a separate laundry room, which had sufficient and appropriate equipment to meet the laundry needs of the number of residents accommodated. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers, skill mix and competencies of staff on duty met residents’ needs. The recruitment procedures were thorough and ensured the protection of residents at the home. EVIDENCE: There was a duty rota showing the names and grades of staff and what hours they worked. The number of staff rostered for duty was sufficient for the number of residents living at the home. There was a Registered Nurse on duty 24 hours per day. There was at least one member of Domestic staff and a Cook and a Kitchen Assistant on duty each day. Six of the resident surveys returned said that staff were always available when they needed them and four said they usually were. There was an overlap period of one hour over lunchtime and teatime when the number of carers on duty was increased. There was also an overlap of one hour between for the Registered Nurses on duty. This enabled them to give a thorough report on the residents’ conditions. The recruitment procedures included completion of an application form, a faceto-face interview, obtaining of references and a POVA First and CRB check. The The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 21 files for two new employees were checked. These showed that the procedures had been followed and all relevant details had been obtained. A member of staff spoken to described her recruitment and this also showed that the procedures had been followed. All files had proof of identity, including a photograph. All new care staff completed the 12 week Skills for Care Induction programme. A completed booklet was seen for one member of staff. There were training records to show that staff had regular updates in safe working practices. Each staff member had an individual training folder that recorded what they had done and on what date. A random selection of thse were examined and they showed that all manadatory training had been done. Staff spoken to confirmed that they did regular training. Other courses than mandatory training had been done by some staff. This included: care of the aging skin; food supplements; sip feeds, continence care; bowel care; blood monitoring; waste control. All staff had done a short dementia awareness training session and some were enrolled on the level 2 course in dementia. There were 23 carers employed, of which 19 had the NVQ level 2 in care. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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. The home was well managed and this ensured that it was run in the best interests of the people who lived there. Systems were in place that ensured the health, safety and welfare of the residents and staff was protected EVIDENCE: The day-today administrative management of the home was done by one of the registered persons who was the registered manager. She had many years experience of running a care home and was currently doing the NVQ level 4 Manager’s Award. There was a job description for Manager and the responsibilities on this were divided out between the registered person and the The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 23 care manager. All staff spoken to said the registered manager and the care manager were approachable and supportive. A lot of in-house audits were done. These were based on the National Minimum Standards for Older People and identified if the home was meeting these or not. There was a summary of performance and an action plan. For example the summary for daily life audits showed that more community based activities were needed and the action plan was for researching where coffee mornings were held in the area. An annual survey was done. The results of 2006 survey had been sent out in a newsletter to all relatives. The newsletter went out every 3 months and told relatives what changes had been made/proposed, what activities had been done/proposed, and generally kept the relatives up to date. Resident meetings were held and minutes recorded. There were trained staff meetings. The handover time was used as a means of asking for the views and ideas of all staff of how things could be improved. This was also done at training sessions. The manager said that supervision another method of getting staff views. Staff spoken to confirmed that they could raise isuses at supervision. The arrangements for handling residents’ money were safe. They ensured that these were kept in a safe manner and that there were records to demonstrate what money had been deposited and withdrawn. The registered manager was appointee for two residents. Money was held in a safe for some residents. The balance of money held for residents picked at random was checked. This was found to be correct with the balances recorded. Receipts were given for any money or valuables handed over for safekeeping. All maintenance checks and servicing was done as required and there were certificates to prove this. The fire alarms were checked weekly. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 24 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The discrepancy between the Controlled Drug register and the balance of medications in the cupboard must be investigated so that it can be assured that medicines are being given correctly. Timescale for action 30/06/07 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. 2. 3. 4. Refer to Standard OP7 OP7 OP8 OP19 Good Practice Recommendations The review of the care plan should given an indication of the progress made during the month so that it can be seen whether the care being given is effective or not. If a resident’s problem or need changes significantly this should be rewritten so that the plan tells staff what is the correct care to e given There should be a programme of maintenance for bedside rails that ensures they are correct for the bed frame and mattress and do not present any danger to residents. All bedroom doors should close fully so that there is no risk to the resident if there is a fire. DS0000022498.V332694.R01.S.doc Version 5.2 Page 26 The Hollies Nursing & Residential Home 5. OP19 Action should be taken to explore alternative floor covering in certain rooms where there is an odour so that the room remains pleasant to live in. The Hollies Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Nursing & Residential Home DS0000022498.V332694.R01.S.doc Version 5.2 Page 28 - 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. 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