Care Home: Holly Bank Care Home

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What the care home does well Service users have their needs assessed before they move to the home, to ensure that the staff team can meet their needs. Service users are treated with respect and have their dignity maintained. Visitors are made to feel welcome. Access to appropriate medical services in the community is enabled in a timely manner. There is appropriate equipment which is well maintained and which staff are trained to use, to assist service users in their daily living. Service users are safe, and confident that complaints will be listened to. What has improved since the last inspection? No statutory requirements were made at the last key inspection. Good practice recommendations had been addressed. Considerable resources have been used to improve the physical environment, with the needs of the service users influencing the improvements. What the care home could do better: The internal care plan review process needs to be undertaken more thoroughly to ensure that care plans are updated to reflect any change in circumstances of the service user. This is to ensure that staff can be confident that information in the care plan is accurate and up to date. Staff should be reminded of the reason for maintaining records. This is to ensure that if they are recording a problem, they take responsibility for starting some action to address the problem. Since the previous key inspection the owner has recruited an acting manager who had been in post for sometime and was undergoing the registration process with the Commission.Holly Bank Care HomeDS0000066359.V376557.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Holly Bank Care Home 70 Manchester Road Heywood Rochdale Lancashire OL10 2AW Lead Inspector Steve Chick Key Unannounced Inspection 16th June 2009 10:00 DS0000066359.V376557.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Bank Care Home Address 70 Manchester Road Heywood Rochdale Lancashire OL10 2AW 01706 623388 F/P 01706 623388 hollybankmanager@eaglecarehomes.orangehome.co.uk www.elderlyresidentialcarehomerochdale.co.uk Eagle Care Homes Ltd 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) Manager post vacant Care Home 38 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (38) of places Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 38) Dementia - Code DE (maximum number of places: 27) The maximum number of service users who can be accommodated is: 38 Date of last inspection 21st November 2007 Brief Description of the Service: Holly Bank is a large detached house standing in its own grounds. It has been extended to provide accommodation for 38 older people, providing personal care for all. Thirty-eight single rooms are provided, all of which are en suite. The home is situated in a residential area on the outskirts of Heywood and is on a main bus route. A local shop and Post Office are situated nearby and there is a public bowling green to the side of the home. Ramped access is provided to the home. The area outside the conservatory has been landscaped to provide a large patio with a water feature. Car parking is available to the front and side of the home. The most recent Commission for Social Care Inspection (CSCI) report was available in the entrance area. At the time of this inspection weekly fees were between £370.46 and £404.25 per week. Additional charges were for hairdressing, aromatherapy, chiropody, toiletries, newspapers, dry cleaning and laundering of delicate fabrics. Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. We (the Care Quality Commission) undertook a key inspection, which included an unannounced visit to the home. This meant that no one at Holly Bank knew that the visit was going to take place. We were accompanied by an expert by experience. This is a person who has experience of using services for older people and has received training in taking part in and contributing to the inspection process. For the purpose of this inspection one service user and one relative of a service user were interviewed in private, as was one visiting professional. Three staff members were also interviewed in private. Additionally discussions took place with the acting manager and the area manager. All the key inspection standards were assessed at the site visit. We also looked at information we have about how the service has managed any complaints, what the service has told us about things that have happened in the service, these are called notifications and any relevant information from other organisations. The management of the home filled in a questionnaire, called an Annual Quality Assurance Assessment (AQAA). This is a legal requirement. The AQAA told us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, some of these comments have been included in the report. We undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints log. We are aware of two safeguarding investigations being undertaken since the previous key inspection. People who we spoke to were positive about the service provided at Holly Bank. Comments included: “[the] girls are absolutely brilliant”; “it is always a pleasure to come in” The expert by experience was positive about what she saw. She told us that she found staff appeared to have a pleasant polite manner and residents were Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 6 content with their ability to communicate their needs with little stress and frustration.” What the service does well: Service users have their needs assessed before they move to the home, to ensure that the staff team can meet their needs. Service users are treated with respect and have their dignity maintained. Visitors are made to feel welcome. Access to appropriate medical services in the community is enabled in a timely manner. There is appropriate equipment which is well maintained and which staff are trained to use, to assist service users in their daily living. Service users are safe, and confident that complaints will be listened to. What has improved since the last inspection? What they could do better: The internal care plan review process needs to be undertaken more thoroughly to ensure that care plans are updated to reflect any change in circumstances of the service user. This is to ensure that staff can be confident that information in the care plan is accurate and up to date. Staff should be reminded of the reason for maintaining records. This is to ensure that if they are recording a problem, they take responsibility for starting some action to address the problem. Since the previous key inspection the owner has recruited an acting manager who had been in post for sometime and was undergoing the registration process with the Commission. Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Holly Bank Care Home DS0000066359.V376557.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 Holly Bank Care Home DS0000066359.V376557.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 does not apply to Holly Bank) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users’ needs are appropriately assessed before moving to the home to ensure that their needs can be appropriately met. Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 10 EVIDENCE: We were told in the AQAA that service users’ needs are assessed prior to admission. We looked at a selection of files relating to service users living at the home. All had a record of an assessment having been undertaken before the person moved into the home. We talked to a visiting social care professional who confirmed that staff from the home had visited the service user to undertake an assessment before the placement was finalised. The expert by experience who was present for some of the visit noted that every bedroom she saw had a user guide prominently placed in it. Holly Bank does not offer intermediate care. Holly Bank Care Home DS0000066359.V376557.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users’ health, personal and social care needs are met by the consistent implementation of policies and procedures. Staff practices also serve to promote the dignity of the service users. EVIDENCE: We looked at a number of service users’ records. All had a written care plan and there was documentary evidence that these plans were periodically reviewed. The area manager told us that service users were involved in discussions about their assessed needs and the plan of care. We were also Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 12 told that this involvement varied depending on the capacity of the service user. We were also told that, where appropriate, families are involved in this discussion. We also saw some documentary evidence, such as family member signatures, to demonstrate their involvement in the care planning process. We spoke to a visiting professional who was confident that family members had been involved in discussion with staff of the home, about the care their relative needed. We spoke to one visiting relative who confirmed that they were involved in reviews of their relative’s care. The written care plans varied in detail. One particular example was seen where good, detailed advice and information was given to staff in connection with the best way to approach that specific service user. Staff who we asked, told us that in addition to the written records there was a verbal handover at each shift change. Staff who we spoke to, were confident that the overall system gave them accurate and up-to-date information about each individual service user. There was documentary evidence that service users had access to professional healthcare staff based in the community. This included general practitioners, district nurses, podiatrists and opticians. A visitor told us that they were confident that they would be informed if their relative was unwell. All staff and visitors who we asked, were confident that medical support would be requested for service users in a timely manner. The home has a medication policy and procedure which, we were told, was reviewed in September 2008. Most medication was seen to be stored appropriately. However, the medication refrigerator had been recorded as having a temperature which was too high since the fifth of June 2009. There was no clear evidence that any attempt had been made to rectify this. A small sample of medication administration records was looked at and presented as being appropriately maintained. This helps to ensure that staff can demonstrate that the correct medication was given to the correct service user at the correct time. Since the previous visit one potentially serious medication administration error, apparently caused by an outside agency, had been identified by the owner. This was still under investigation at the time of this visit. A relative of the service user involved told us they were pleased with the response once the error had been identified and that they felt that they had been kept informed of subsequent actions taken. We were told in the AQAA that each member of staff received induction training which included the promotion of privacy and dignity for service users. One visitor told us that she couldnt fault the way her relative was treated by the staff. Staff who we asked, told us that service users were treated with respect and had their dignity maintained. Observations from the expert by experience included that all staff appeared to have a pleasant and polite Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 13 manner, and all residents appeared content with their ability to indicate their needs with little stress and frustration. Holly Bank Care Home DS0000066359.V376557.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. An appropriate range of activities is available to service users, and visitors are welcome in the home, which enhances service users fulfilment and social stimulation. The provision of food to maintain service users health and wellbeing is good. EVIDENCE: In the selection of care plans looked at there was evidence of the individual’s social history and background being recorded. The detail in these records varied considerably. Discussion with the area manager indicated that this was largely a reflection of the varying information passed to them by the service user or their family. A social history is important to assist staff in Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 15 understanding the background of each individual and any interests, hobbies or routines which are important to them. The expert by experience commented that there was quite a list of activities for service users to participate in, depending on their health, capacity and wishes. We were told that an independent person who ran an activities company was employed on a fortnightly basis to produce positive motivation and encouragement for both service users and staff. Hairdressing and a clothes party had been arranged on the afternoon of our visit. The relative of one service user visited to wash and blow dry her mothers hair. This appeared to be enjoyed by the service user. There was a designated activities room with a small quiet room attached. Service users were observed to be using all the communal areas and were free to spend time where they wished. Staff who we asked told us that service users were able to exercise choice, for example, in deciding when they got up and when they went to bed and where they spent time during the day. We were told that visitors were welcome at any reasonable time. This was confirmed by visitors we spoke to, who also told us they received a warm welcome by the staff. One meal was sampled during the unannounced visit to the home. It was tasty and pleasantly presented. Staff and the visitor who we asked confirmed that there was always a choice of food. The expert by experience observed that the food looked well cooked and was presented as each service user required. The expert by experience noted that the chef had a cheerful demeanour and that their friendly nature was reflected in the manners of the younger staff who all appeared to work together as a pleasant team. The expert by experience also identified posters on the dining room wall advertising ice cream and simple snacks should they be required. Various drinks were seen to be available at all times, with jugs of cold drinks being made available in the lounges. Holly Bank Care Home DS0000066359.V376557.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are protected from abuse or exploitation by the home’s policies and practices and are confident that any complaints they may have would be dealt with appropriately. EVIDENCE: Holly Bank has a complaints procedure which has been found to be appropriate on previous occasions and was not looked at during this visit. We were told in the AQAA that a record was kept of all complaints and any investigations carried out. We looked at the log of complaints maintained at the home. This presented as being appropriately maintained, although only recorded formal complaints. A record of informal complaints or comments can be a useful managerial tool to identify, at an early stage, issues which may benefit from being addressed to enhance the quality of the care provided. Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 17 Visitors and staff who we asked were confident that complaints would be listened to and addressed by the management team. The home also kept a record of compliments received. One complimentary letter had been received on the day of this visit. Since the last key inspection there had been two safeguarding alerts of which we were aware. These were instigated by the management team at Holly Bank following appropriate procedural guidance relating to the protection of vulnerable adults. At the time of writing this report both matters were still under investigation, although appropriate action to maintain the safety of the service users had been undertaken by Holly Bank. We looked at a selection of training records which indicated that most staff had received training in connection with the protection of vulnerable adults. Staff who we talked to presented as understanding the need to remain vigilant in connection with the possibility of abuse or exploitation of the service users. They told us that they felt service users were safe at Holly Bank and that they understood their responsibility to whistle blow if necessary. Holly Bank Care Home DS0000066359.V376557.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is appropriately maintained, decorated and cleaned to enable service users live in a pleasant, safe and hygienic environment. EVIDENCE: Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 19 During this unannounced visit to the home a tour of the building was undertaken. This included the communal areas and a selection of service users’ bedrooms. We were told that since the last visit alterations had been made to the building including creating a link between two wings of the building allowing service users to walk freely around the home. There is a new ramped access to the front entrance and we were told that new carpets, chairs, curtains and other domestic equipment had been purchased. There was a large well maintained garden which service users could access under supervision. Service users’ bedrooms showed signs of personalisation. The visitor we talked to confirmed that their relative had been able to personalise their bedroom including by bringing in furniture and a small refrigerator. The expert by experience commented favourably on the building noting that the decor was clean but in need of some refurbishment in places, but this was nothing which would not be expected in a care home. No items in connection with the physical environment were identified which needed to be addressed. The expert by experience also commented on what she thought was a very clean kitchen and the well organised laundry system. The owner told us that since the last key inspection a new kitchen had been fitted. At the time of this unannounced visit, the home presented as clean and tidy with no unpleasant odours. Staff and visitors who we spoke to said that this was the usual state of the home. Holly Bank Care Home DS0000066359.V376557.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skills mix of staff on duty promotes the independence and well being of service users. Recruitment and vetting procedures are effectively applied to minimise the risk to service users of inappropriate staff being employed. EVIDENCE: We were told that staffing is usually provided on the basis of a team leader and three carers between 08:00 and 15:00 and 15:00 to 22:00. Two carers are on duty at night, between 22:00 and 08:00. Additionally there are cooks, kitchen staff and domestics including a dedicated laundry assistant. We were provided with a copy of the staff Rota for the week beginning the eighth of June as evidence of this. The Area Manager told us she was confident that these staffing levels were appropriate to meet the needs of the 25 service users who were resident at the time. Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 21 We were told in the AQAA that 20 of the 22 care staff held an NVQ two (or higher) in care. The NVQ is a nationally recognised qualification intended to improve the knowledge and skills base of carers to improve the care service they offer. We were told in the AQAA that staff recruitment was undertaken thoroughly. We looked at a sample of records relating to the recruitment and vetting of staff since the last key inspection. These records indicated that appropriate information had been received from the applicant, referees and the CRB (criminal records bureau), before the person started working at Holly Bank. This is important as it enables the management to make an informed decision as to the applicant’s suitability to work with vulnerable service users. We were told that all staff received a period of induction training. This was confirmed by staff who we spoke to. Staff who we asked, told us that they were supported to undertake training. We looked at training records for a sample of staff these included training in connection with the protection of vulnerable adults, dementia and moving and handling. One person whose file we looked at, was booked onto a moving and handling course in August 2009. They had been in employment approximately 8 months and we were told by the area manager that they had received inhouse training and guidance in connection with moving and handling techniques as a part of their induction. Holly Bank Care Home DS0000066359.V376557.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management team use the quality audit systems and implement the health and safety procedures for the benefit of service users and staff. EVIDENCE: Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 23 The home has been without a registered manager for approximately 2 years. During this period several acting managers have been in post but none have completed the registration process with the Commission. Since the last registered manager was in post the area manager has maintained a high profile and helped to maintain standards. However, it is a legal requirement for a care home to have a manager in post, who is registered with the commission. This is to ensure that the manager is ‘fit’ to hold that position and to ensure that the person responsible for the day-to-day running of the home is also legally accountable for the way the home is run. All care homes are legally required to return to the commission an AQAA (annual quality assurance assessment). The purpose of this document is to allow the home to undertake a self-assessment, and to tell us what they think they do well, what they need to do better and what they have improved upon. The manner in which the AQAA was completed did not clearly demonstrate that the management team were taking responsibility for planning for future development and improvement within the home. There was documentary evidence that regular quality audits are undertaken which include seeking the views of service users and their representatives. The outcome of the consumer survey undertaken in March 2009 was displayed on the notice board. We looked a selection of records of money held by the home, on behalf of service users. These records presented as being appropriately maintained to safeguard the interests of service users. For example receipts were seen which related to items purchased on behalf the service users. We were told in the AQAA that all the required health and safety checks and routine maintenance tasks were undertaken. A small selection of records was looked at to confirm this. These included confirmation of the lift and the fire detection and alarm systems being appropriately maintained. Holly Bank Care Home DS0000066359.V376557.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 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP31 Regulation 8 Requirement The registered person must ensure that an application is made to the commission for the registration of a suitable person to be the manager at Holly Bank. Timescale for action 17/10/09 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 OP8 Good Practice Recommendations The registered person should ensure that if routine checks on equipment, such as the medication refrigerator, demonstrated that it is not working properly, swift action should be taken to rectify the matter. This is to minimise the risk of service users’ medication becoming ineffective through incorrect storage. Holly Bank Care Home DS0000066359.V376557.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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