Care Home: Holly Cottage

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What the care home does well Residents at Holly Cottage clearly benefit from having a competent and experienced manager and a dedicated staff team who are evidently committed to providing a consistent and high quality level of care. Staff work closely with residents and have developed a sound understanding of their individual care and support needs. The relaxed, homely and welcoming environment has evolved over many years and reflects the commitment within the staff team and the open and inclusive management style. Residents are enabled and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities.The home provides good, clear information regarding the abilities and disabilities of residents, with specific staff guidance on how best to support individuals. Personal likes and dislikes are recorded and goal planning works towards specific achievements. Regular reviews are held and routinely involve residents and their relatives. Minutes of reviews were found to be very comprehensive. What has improved since the last inspection? Since the previous inspection, as required, policies and procedures relating to the control, storage, administration and recording of medication have been reviewed. Also since the last inspection a new and larger medicine cabinet has been provided and medication is now stored and recorded appropriately. What the care home could do better: An effective quality monitoring system must be developed and implemented, to actively and regularly seek the views of residents, their relatives and other visitors to the home, as to how the service is achieving goals for residents. Pages in the Statement of Purpose should be numbered, to correspond with the table of contents and ensure information is more readily accessible. It is important that the home`s policies and procedures regarding complaints and adult protection (Safeguarding adults) be reviewed and updated. The institutionalised and unnecessary labels on the chests of drawers in residents` bedrooms should be removed. CARE HOME ADULTS 18-65 Holly Cottage 1 Mill Lane Balcombe Nr Haywards Heath West Sussex RH17 6NP Lead Inspector Nigel Thompson Unannounced Inspection 1st November 2007 10:00 Holly Cottage DS0000066067.V349708.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 Holly Cottage DS0000066067.V349708.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. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Cottage Address 1 Mill Lane Balcombe Nr Haywards Heath West Sussex RH17 6NP 01444811109 F/P 01444811109 hollycottage@evesleighcaregroup.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) Evesleigh Care Homes Ltd (ILIACE Group) Ms Patricia Margaret Hyland Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 4 service users in the categories listed above may be accommodated at any one time. 26th April 2006 Date of last inspection Brief Description of the Service: Holly Cottage is a care home registered to accommodate up to four Service Users with learning disabilities. The Registered Provider is Evesleigh Care Homes Ltd and the Registered Manager is Ms Pat Hyland. The home is a semi-detached property, situated in a small rural village in Balcombe, which is situated between Haywards Heath and Crawley and therefore has access to all community facilities and is within easy reach of local rail and bus stations. Accommodation is provided over two floors. Each resident has their own bedroom, with a bedroom located on the ground floor, and the remaining three rooms on the first floor. On the ground floor there is a living room, an activity room and a large kitchen that includes a dining area. In addition the home has a garden with lawn and decking to the rear of the property. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective residents or their relatives, on request, as part of the admission process. The current range of fees at Holly Cottage, as of 1st November 2007, is £1,000- £1,300 per week. Additional charges are made for hairdressing, chiropody, toiletries and clothes. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over five and a half hours in November 2007. It found that the majority of the key National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Residents observed and spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were four residents living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with three residents two members of staff and the registered manager. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: Residents at Holly Cottage clearly benefit from having a competent and experienced manager and a dedicated staff team who are evidently committed to providing a consistent and high quality level of care. Staff work closely with residents and have developed a sound understanding of their individual care and support needs. The relaxed, homely and welcoming environment has evolved over many years and reflects the commitment within the staff team and the open and inclusive management style. Residents are enabled and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 6 The home provides good, clear information regarding the abilities and disabilities of residents, with specific staff guidance on how best to support individuals. Personal likes and dislikes are recorded and goal planning works towards specific achievements. Regular reviews are held and routinely involve residents and their relatives. Minutes of reviews were found to be very comprehensive. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that residents are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective residents know that the home is able to meet their individual care and support needs. EVIDENCE: Comprehensive information relating to the home is made available to all prospective residents, their relatives and associated care managers. Relevant documentation including the Statement of Purpose ‘ and ‘Service User Guide’ was examined and found to be generally satisfactory. However, following discussion with the manager, it is recommended that the largely generic Statement of Purpose be reviewed and amended to form a more concise, detailed and service specific document. To ensure information is more readily accessible, it is also recommended that pages in the Statement of Purpose be numbered, to correspond with the table of contents. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 9 Following a referral to the home, one of the management team will visit the prospective resident and carry out a full pre-admission assessment, including any personal and emotional care and support needs, mobility issues, social and cultural needs and family involvement. There have been two residents admitted to Holly Cottage since the previous inspection and in individual files that were examined it was evident that a full needs assessment had been undertaken in each case. Of particular note was the detailed and very comprehensive ‘Placement Assessment Report’ that had been completed in respect of one resident who has recently moved into the home. As well as establishing whether an individual’s care and support needs can be met within the home, the manager also stressed the importance of ensuring compatibility with existing residents. Therefore, in addition to the written assessment and as part of the admission process, prospective residents are invited to visit the home to look around and meet with existing residents and staff. They may also have the opportunity for an overnight stop or a weekend stay, before moving in. The manager confirmed that all new residents undergo a flexible trial period at the home, during which time their suitability and compatibility are fully assessed and it is established whether their identified care and support needs are able to be met. The effectiveness of the home’s admission procedure and assessment process was evident from positive comments received from a resident’s relative: ‘Having been given the opportunity of assessing several care homes of similar type and comparing them with my first impressions of Holly Cottage, there was little doubt in my mind that it was the home most suitable for my son’. In documents that were examined it was evident that individual contractual agreements had been signed and dated by the resident themselves, or a relative or representative on their behalf. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ care plans enable staff to meet assessed needs in a structured and consistent manner and individual plans, including risk assessments reflect changing support needs. Systems for consultation and participation remain effective and residents are treated with respect and are encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: Person centred care plans (Support Plans) have been thoughtfully developed for each resident and are clearly linked to the individual’s assessed needs. The plan, covering in detail ‘the person’ and ‘the support’ is formulated by the key-worker, manager and evidently with the direct involvement of the resident or family member, as appropriate. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 11 In a sample of personal files that were examined, it was evident that recent reviews had taken place. Plans were found to be comprehensive and linked to the individual’s current assessments, containing risk assessments and detailed guidance for staff on how to meet identified care and support needs in a structured and consistent manner. The manager confirmed that all staff are expected to sign guidelines to confirm that they have read and understood the relevant information. She added that the individual resident themselves and, where appropriate, a relative or representative have the opportunity to be involved in regular care plan reviews. Staff spoken with during the inspection confirmed that, despite the variable and limited verbal communication of some residents, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting residents in a professional, sensitive and respectful manner. Residents are evidently encouraged to take responsible risks where necessary in order to promote their independence. Detailed risk assessments and guidance are in place for all activities of daily living, based on the needs of individuals. All risk assessments have been recently reviewed and updated as necessary. Independence and individuality is evidently encouraged and promoted within the home and is reflected in the personalising of residents’ rooms, the choice of bedclothes and colour schemes and individual preferences for occupational and leisure activities. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Residents benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of residents are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 13 Residents are fully supported to access a range of occupational and recreational activities and facilities to meet their individual needs and preferences. Activities include attending a workshop, exercise sessions, shopping, going to clubs, pubs and cafes and various trips out. Individual weekly activity programmes have been developed and are specifically tailored for each resident and take account such factors as age, health, capacity and mobility. It was noted that one resident continues to be employed part time in a local school, where he is fully supported to carry out routine maintenance work. On the day of the inspection, one resident was clearly enjoying accompanying and helping the maintenance man, to select, purchase and put up bookshelves in his own room. The manager confirmed that, where appropriate, residents’ family links continue to be supported, however family contact is variable. A four-week rolling menu has been developed following consultation with residents. Meals are evidently varied and balanced and are based on residents’ identified likes and preferences. An alternative to the main meal is always available. All meals are prepared within the home by care staff who have attended a Food Hygiene course. Residents are encouraged as appropriate to participate in food preparation. Individuals are evidently offered discreet support as necessary at mealtimes. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with residents and demonstrate an awareness and sound understanding of their individual care and support needs. Residents are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: In accordance with their personal care plan, residents at Holly Cottage are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, residents were observed being supported in a sensitive, professional and respectful manner by members of staff. Documentary evidence was in place to demonstrate that the health and emotional care needs of residents continue to be met within the home. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 15 Individual care plans that were examined were found to contain detailed information, clearly developed through close consultation with and direct involvement of residents and their relatives. The manager confirmed that close and effective working relationships between residents and their key worker ensure that any subtle change in an individual’s mood or behaviour can be identified and addressed at an early stage. All residents are registered with local GPs and have access to other health care professionals, including physiotherapists, psychologists, speech and language therapists and occupational therapists, as required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Since the previous inspection, as required, policies and procedures relating to the control, storage, administration and recording of medication have been reviewed. A new and larger medicine cabinet has been provided and it was noted that medication is now stored and recorded appropriately. All staff responsible for administering medication have received training and are individually assessed and authorised to do so. This was confirmed by staff spoken with during the inspection and evidenced by training records examined. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure should be reviewed to ensure that residents, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. Residents are protected, through policies and procedures relating to abuse and adult protection. However this documentation must also be reviewed and updated to reflect the current situation. EVIDENCE: A clear, simple and concise complaints procedure has been developed for the benefit of residents, which includes photographs of the people to speak to or contact regarding their concerns. However, it is evident that the policy and procedure have not been reviewed since January 2006 and the photographs include staff that no longer work for the organisation. This was confirmed by the manager, who added: ‘At managers’ meetings, we are always complaining that this policy and procedure is out of date.’ Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 17 The manager confirmed that close working relationships, effective and ongoing communication and consultation and regular residents’ meetings provide adequate opportunities for any concerns to be raised and discussed, before they become complaints. This was supported by residents and members of staff, spoken with during the inspection, who confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. It was noted that there have been no concerns or complaints recorded by the home since the last inspection. Detailed policies and procedures have been developed, relating to adult protection and abuse, including a whistle blowing policy. These documents have evidently been drawn up in accordance with the West Sussex multi agency guidelines for the protection of vulnerable adults. All staff are expected to sign to confirm that they have read and understood the documents. However it was noted that the last entry was July 2006 and the policies and procedures were last updated in 2004. The manager confirmed that all care staff have undertaken appropriate training regarding abuse awareness. This was supported through discussions with members of staff during the inspection and evidenced through individual training records, which indicated that relevant training had been provided earlier this year. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Residents benefit from pleasant accommodation that is comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: During my ‘guided tour’ of the premises it was evident that the well maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and generally homely environment for residents. This was also supported by comments received from residents’ relatives: Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 19 ‘The atmosphere seems to be homely, rather than institutionalised, which I welcome’. Since the previous inspection, it was noted that two residents’ bedrooms have been redecorated and one room has had a new carpet fitted. The manager confirmed that independence and individuality continue to be promoted within the home and, as previously documented, this is evident from the personalising of residents’ rooms, reflecting individual preference and interests. However this ethos unfortunately did not extend to the institutionalised and unnecessary labelling on chests of drawers in many of the bedrooms. The manager confirmed that this was a long-standing practice that was probably introduced to make life easier for staff - but in reality was of no direct benefit to the residents. Identified maintenance requirements are documented and addressed by the maintenance man, as necessary. Infection control policies and procedures are in place and clearly adhered to. Residents and their key workers are responsible for keeping bedrooms clean and tidy and on the day of the inspection, levels of cleanliness and hygiene throughout the home were found to be satisfactory. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents benefit from there being sufficient trained and competent staff on duty at all times to meet their assessed care and support needs. Residents are protected by satisfactory staff recruitment procedures, training and supervision. EVIDENCE: Through discussion with the manager, care staff and residents, it is evident that sufficient staff are employed to meet the current assessed support needs of residents and to ensure consistency and continuity of care. The manager confirmed that agency staff are not employed in the home, however, staffing levels are closely monitored and are directly linked to the residents’ current identified levels of dependency. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 21 Positive comments from residents’ relatives reflect a high level of satisfaction with the staff and the services provided: ‘The carers at Holly Cottage, supervised by the manager, are very friendly and relaxed, treating all the residents with respect and dignity’. A duty rota has been developed and implemented to detail the staff on duty at any given time and their designation. In addition to a comprehensive induction programme, appropriate core skills training is provided for all care staff, including first aid, moving and handling, food hygiene and fire safety. Specialist training, including ‘Epilepsy awareness’ is provided as necessary to meet the needs of individual residents and give staff: ‘…a greater understanding of the condition and issues’. This was confirmed through discussions with staff, including a dedicated training manager and evidenced by records examined and an informative training matrix, which is updated by the manager on a monthly basis: ‘Training here is definitely improving ’. Formal and structured staff supervision is provided on a regular basis and is appropriately recorded. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of residents. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents benefit from a competent management structure. They are protected by satisfactory health and safety procedures but their best interests are not always safeguarded by the current ineffective and inadequate quality monitoring systems. EVIDENCE: The experienced manager has been in her current post since February 2006 and is evidently competent and well qualified to run the home, having recently completed her NVQ level 5, in management and care. She already holds the Registered Manager’s Award (RMA) as well as NVQ level 4. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 23 From direct observation and through discussions with residents and members of staff, it is evident that the manager continues to demonstrate a clear sense of leadership and direction. She is clearly motivated, positive and approachable and continues to create an open and inclusive atmosphere within the home. Quality monitoring systems within the home are currently inadequate and, following discussion with the manager, it is clear that the issue has not been considered a priority in recent months. There was little documentary evidence that the views of residents, their relatives or other visitors to the home have been sought in any formal or structured manner. The manager confirmed that the health, safety and welfare of residents and staff remain of paramount importance within the home. As previously documented, staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is satisfactorily recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Fire alarm systems are regularly checked and records maintained. Temperature regulators are fitted to all hot water outlets, accessible to residents. All accidents, incidents and injuries are recorded and reported, as required. Holly Cottage DS0000066067.V349708.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 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 3 2 3 3 3 4 3 5 3 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 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 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 Holly Cottage DS0000066067.V349708.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 YA39 Regulation 24 (1) & (3) Requirement It is required that an effective quality monitoring system be developed and implemented, to actively and regularly seek the views of residents, their relatives and other stakeholders, as to how the service is achieving goals for residents. Timescale for action 31/12/07 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 YA1 YA1 YA22 YA23 Good Practice Recommendations It is recommended that the largely generic Statement of Purpose be reviewed and amended to form a more concise, detailed and service specific document. It is recommended that pages in the Statement of Purpose be numbered, to correspond with the table of contents and ensure information is more readily accessible. It is recommended that the home’s current complaints policy and procedure be reviewed and updated. It is recommended that all policies and procedures relating to abuse and safeguarding adults be reviewed and updated. DS0000066067.V349708.R01.S.doc Version 5.2 Page 26 Holly Cottage 5. YA26 It is recommended that the labels on the chests of drawers in residents’ bedrooms be removed. Holly Cottage DS0000066067.V349708.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holly Cottage DS0000066067.V349708.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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