Care Home: Holly House (Beechley)

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What the care home does well People appeared to be relaxed in their home; there was a pleasant atmosphere and good rapport observed between residents and staff. There is a person centred approach to care planning and supporting people and care plan reviews and risk assessments have been regularly reviewed to make sure that staff have up to date guidance about how to support people. There was a lot of evidence of consultation with people through residents` meetings, quality monitoring surveys and life books. In this way people are able to have a say about the lifestyle and culture in Holly House. People`s diversity is respected through making arrangements for them to follow their chosen beliefs and helping them to follow their chosen lifestyle. For people who are physically frail, a range of disability equipment is provided and for those who have communication difficulties, their preferred communication methods are documented and specialist support obtained if needed. Staff showed commitment to protecting people through following "whistleblowing" and alerting procedures where there was an allegation of abuse. The organisational disciplinary and safeguarding procedures have been followed and well documented and action taken to avoid any future occurrence. What has improved since the last inspection? Since our last visit, the statement of purpose and service user guide have been set out with illustrations to help people who may have difficulty reading them. Wound care protocols are being followed and only individually prescribed dressings are used for people. Referrals have been made to the tissue viability nurse for people who are at risk of pressure sores. In response to quality assurance survey outcomes, remedial action will be taken where residents identify areas for improvement. In this way people have a say in the way their home is developed and managed. What the care home could do better: An area of the home has been identified where a residents` laundry is to be set up and the work on this due to start. It is recommended that this work be given priority, as provision of a residents` laundry will help to develop people`s independence and skills. In the information sent to us before our visit, the manager has recognised a number of areas of service where improvements are planned in the near future. Some of the intended changes referred to are improvements to the range of activities (such as holidays) and more educational opportunities for people. There is to be continuing refurbishment of the home and increased inhouse facilities in response to requests from residents for a pool table and computer. CARE HOME ADULTS 18-65 Holly House (Beechley) Harthill Road Liverpool Merseyside L18 3HU Lead Inspector Patricia Thomas Key Unannounced Inspection 21 July 2008 11:00 Holly House (Beechley) DS0000047937.V366100.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 House (Beechley) DS0000047937.V366100.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 House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly House (Beechley) Address Harthill Road Liverpool Merseyside L18 3HU 01325 351 100 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) beechley@schealthcare.co.uk Not available Active Care Partnerships Ltd Anne Fitzpatrick Care Home 30 Category(ies) of Learning disability (20), Physical disability (10) registration, with number of places Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17 July 2006 Brief Description of the Service: Holly House is located the Allerton area of Liverpool. The home is owned by Active Care Partnerships Ltd, which has similar homes both locally and nationally. Holly House is a three storey house set in large attractive grounds and is easily accessible by bus and car. The home accommodates up to thirty younger adults with a learning or physical disability who need personal or nursing care. Accommodation consists of twenty-six bedrooms, twenty-two single and four doubles. Nineteen of the rooms have en-suite facilities. The remaining bedrooms have wash hand basins. The weekly charge for this service is £828.00 per week with extra charges for hairdressing, chiropody and newspapers. Holly House (Beechley) DS0000047937.V366100.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 stars. receiving the service have good quality outcomes. This means that people To assess Holly House, we (the commission) carried out an unannounced visit to the home. We spoke with residents, staff and the manager, Anne Fitzpatrick. We looked at records maintained in the home about care, health & safety, complaints and staffing. This was to make sure people are being supported properly and safely while they are living there. The manager had completed a detailed questionnaire and returned it to us before the visit. It gave us a lot of information about the home, what is done well and what could be improved. People living in Holly House did not comment in depth about their home and we gathered a lot of evidence through direct observation during our visit. What the service does well: People appeared to be relaxed in their home; there was a pleasant atmosphere and good rapport observed between residents and staff. There is a person centred approach to care planning and supporting people and care plan reviews and risk assessments have been regularly reviewed to make sure that staff have up to date guidance about how to support people. There was a lot of evidence of consultation with people through residents’ meetings, quality monitoring surveys and life books. In this way people are able to have a say about the lifestyle and culture in Holly House. People’s diversity is respected through making arrangements for them to follow their chosen beliefs and helping them to follow their chosen lifestyle. For people who are physically frail, a range of disability equipment is provided and for those who have communication difficulties, their preferred communication methods are documented and specialist support obtained if needed. Staff showed commitment to protecting people through following “whistleblowing” and alerting procedures where there was an allegation of abuse. The organisational disciplinary and safeguarding procedures have been followed and well documented and action taken to avoid any future occurrence. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 6 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 House (Beechley) DS0000047937.V366100.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 House (Beechley) DS0000047937.V366100.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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People have had their needs assessed and are given plenty of information about the home before they choose to move in so they know their needs can be met at the home. EVIDENCE: The information the manager sent us before our visit tells us that, “Issues relating to equality and diversity are incorporated into our assessment and care planning process. The home ensures that individual service users with specific cultural, spiritual or sexual needs and /or belief systems are supported in line with their personal choices and/or preferences”. We looked at care files of some of the people who live at the home. All people who move into Holly House have their needs assessed by health and social services staff and staff from the home. In this way staff will know whether the home has the facilities to meet the person’s assessed needs before they move in. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 9 The information we received from the manager confirms that people are invited to visit the home to meet residents and staff to help them make a choice about moving in. They are provided with a copy of the service user guide to give them plenty of information about Holly House. The assessments we saw in people’s files had been carried out in consultation with them. The outcomes covered a range of the person’s health, personal care and social needs and these had been used to set out the person’s care plan. Holly House (Beechley) DS0000047937.V366100.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&9 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People are involved in writing their care plans so they have a say in the way their care will be given and decision making in the home. EVIDENCE: We looked at care plans for two people in detail. The planning of care is person centred, which means it is written with the person and/or their family and they have a say about the way their care will be given. A care plan is set out to meet each identified area of need and related risk assessments are carried out. This is done so that staff have guidance as to how to meet each person’s needs. People’s independence is maintained through identifying and reducing risks to their health and safety. Examples of areas of risk identified were those associated with smoking, use of bedrails and use of the passenger lift. There was evidence in care plans that we looked at that they had been regularly reviewed and amended to address any change in the person’s condition. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 11 People’s diverse and unique needs are recognized through recording their preferences and choices, for example of meals and activities. People’s right to make decisions is promoted through involving them in writing their care plans. For people who have no family to support them, arrangements are made for independent advocates to represent them if necessary. Holly House (Beechley) DS0000047937.V366100.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, 15, 16 & 17 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People living in Holly House have the lifestyle they choose so they have opportunities for personal development, education and taking part in activities inside and outside the home. EVIDENCE: People who live in Holly House have opportunities to attend local colleges to pursue their education. We spoke with a person who has recently gained a qualification and an award as student of the year from college. People’s culture and beliefs are recorded in their care plans and arrangements are made for visits from local eucharistic ministers and church groups. There is an activities co-ordinator employed in the home; we met with a group of people in the activities room, who were taking part in reading, board games, therapy and painting. There was a pleasant atmosphere, and people appeared relaxed in each other’s company. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 13 A kitchen has been installed in the activities room to help develop people’s daily living skills in preparing drinks and snacks. The activities co-ordinator told us a number of people would be going on one of their regular outings later that day. Each person has an individual activities file and life book, which they have written and illustrated with staff. Life books include a social history of the person and details of people, events and things that are important to them. Life books play an important role in giving people opportunities to have the lifestyle they choose in the home and community. People were spending time in different parts of the home, in the lounges, their bedrooms, the activities room and smoking room. The manager said the garden is well used in fine weather. People’s family contact details were recorded in their care files. Where appropriate, family members take part in planning activities. There are weekly staff and resident meetings to make sure people are fully involved in planning what activities take place for them in their home and in the community. During our visit, we saw good interaction between people who live in the home and staff. People who need a lot of support and care, for example at mealtimes, were given the attention they needed and staff did not appear rushed. The menus show a wide range of choices of meals and alternatives are available to people who live in Holly House. There is a pleasant dining room, which has good views of the garden and enough seating and place settings for residents. The food stores were well stocked with fresh, chilled and dry foods and there were choices of breakfast cereals and hot and cold drinks. Holly House (Beechley) DS0000047937.V366100.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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Residents’ person centred care plans are regularly reviewed so they give staff up to date guidance on how to support each person. EVIDENCE: The information sent to us before the inspection tells us of services that are available to people living in Holly House, such as, “Visiting practitioners, including opticians, chiropody and dental screening. The home has an excellent working relationship with GP practices, which ensures ongoing communication and evaluation of services”. At our visit we found there were health care and nutritional plans in place for people in their individual care plans. For those who are physically frail, there is a summary of the person’s mobility and the ways by which they will be supported through use of moving equipment. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 15 People’s methods of communication are recorded, and referrals made to specialist services (such as speech therapists) as needed. There was evidence in care plans that people who live at the home are registered with local doctors and have access to ongoing community health services in addition to support from nursing staff in the home. We saw that pressure care is attended to in the home through providing a person with pressure relieving equipment, staff monitoring pressure areas and assisting the person to regularly change position to avoid a pressure sore developing. There was evidence in a person’s care plan, that since being discharged from hospital, her condition has improved and her health care plan has been reviewed to guide staff in giving her support which is in keeping with her needs. All prescribed medication brought into the home is stored in a locked room to keep it secure. There is a procedure in place on managing medication for staff to follow. We discussed medication for people living in Holly House with the manager during a visit to the storage room. She confirmed the procedures in place for signing in people’s prescribed medication, recording that it has been given to them, and returning any refused/unused medication to the pharmacy. The records were checked and were in good order. In this way, all medication accepted into the home is accounted for. There is a cabinet and separate recording system for controlled drugs; however, there were no controlled drugs in use at the time of our visit. The manager confirmed that only individually prescribed dressing are used for people who need wound care. Holly House (Beechley) DS0000047937.V366100.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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There is a clear complaints process for the home so residents’ complaints are listened to and acted upon. Staff have received training on safeguarding adults so people who live in the home are protected from abuse. EVIDENCE: The information the manager sent us before our visit to the home states, “The home operates a robust complaints procedure which ensures that all complaints are managed swiftly and effectively in line with company policy. Residents, family, friends, visitors and professionals are encouraged to express any concerns about the home or the service”. There has been one concern received at CSCI about Holly House since the last bug inspection and we carried out a short inspection to look at this. We made a requirement about pressure and wound care; this has been met. The findings of this visit were that the home has safeguarding procedures and staff have received training in protection of vulnerable adults since the last visit. There has been one safeguarding referral in recent months, which has been upheld. The manager took the right action by informing CSCI and referring allegations of physical abuse to Liverpool Social Services Safeguarding Team. The allegation was looked into by police and social services and concluded through internal disciplinary procedures. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 17 Two members of staff have been dismissed and referred to the protection of vulnerable adults (POVA) list. The list has been established by the Department of Health to ensure people who have been found to be unsuitable will not be able to work in another care service, as employers are required to check the list before employing care staff. Holly House (Beechley) DS0000047937.V366100.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 & 30 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well maintained and comfortable and work is ongoing so it remains safe and suitable for the people who live there. EVIDENCE: The manager told us in the information she sent us before we visited: “We provide a clean and safe homely environment foir residents. We respond to residents’ opinions and wishes for environmental changes. We provide scenic, well maintained grounds giving space and security and opportunites for outdoor activities. We have provided a new kitchen for residents use to develop and enhance independent living skills”. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 19 During our visit we walked around the house and grounds to look at facilities for residents and cleanliness in the home. It is very large houses and retains many original features. As a care home, it accommodates up to thirty people with ample space giving them a choice of lounges, a dining room, smoking room and activities area with integral kitchen for their use. The grounds are a very attractive feature of this home and people said they enjoy going outside when the weather is fine. The gardens are secluded and are very well maintained with patio and parking areas. Inside, there are utility areas, such as main laundry and offices in the basement and the main kitchen is on the ground floor. There are also staff offices on the ground floor to make sure that there is good contact with the residents. There are bedrooms on the ground and upper floors. There are toilets and specialist bathing facilities throughout the home and most of the bedrooms have ensuite facilites. All the bedrooms which we were able to visit were highly personalised and clean, with fresh bed linen. People had a lot of personal possessions in their bedrooms, some of which show their interests, such as football and music. There is a continuing maintenance programme to make sure that the building is safe and in good condition. Some areas were being decorated during our visit. There are plans to have a residents’ laundry installed, so that people will have the choice to wash their own personal items, subject to risk assessment. There is a range of mobility aids in the home, such as hoists, specialist baths, grab rails, a ramp and a passenger lift to help people move around as independently and safely as possible. Referrals are made to occupational health/physiotherapy for specialist advice if needed. In addition, people have personal mobility aids such as wheelchairs. Those who are at risk of falls have bedrails and bumpers fitted to their beds. People who are at risk of pressure sores use pressure relieving equipment such as matresses and pressure cushions and receive visits from specialist nurses. There was evidence that use of mobility equipment is recorded in care plans and risk assessments carried out and reviewed to ensure equipment continues to be safe for people who may have become frail. Domestic staff are employed; there are systems in place to keep cleaning materials safe and for the control of infection with related procedures and training for staff guidance. The kitchen was hygienic with fittings and utensils being maintained to a high standard of cleanliness. Food storage was satisfactory, with safe storage procedures for fresh, chilled and frozen foods. Catering records had been well maintained. The laundry was well organised with systems for keeping laundered and soiled items separated. Holly House (Beechley) DS0000047937.V366100.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, 34 & 35 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There are enough staff employed with relevant skills and training to make sure the people who live at Holly House are well supported and their needs are met. EVIDENCE: The manager told us in the information she sent us, “We have a full and consistent staff team with a skills mix that includes RGN, RMN and RNLD nurses and care staff with NVQ qualifications. In addition, we have Edge Hill university student nurse placements. We retain staff and provide all mandatory training as required. New staff undergo induction and there are appraisals and supervision in place for all staff. Staff recruitment process that ensures all recruitment is undertaken in line with equal opportunities”. We looked at the staff roster, training schedules and staff files to check staff numbers, skills and the way by which they are recruited. The rosters show there is at least one qualified nurse on duty throughout the day and night. There are two nurses and five care assistants on duty in the morning, with two nurses and four care assistants on in the afternoon. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 21 There is one nurse and two care assistants on duty at night. Ancillary staff consist of chefs, kitchen domestic assistants, general domestic assistants, a laundry assistant and maintenance staff. We spoke with four members of staff who said they are well supported by management and they receive supervision, appraisals and ongoing training. The training schedule shows that mandatory training is ongoing and that staff have received training in protection of vulnerable adults since our last visit. We looked at a sample of staff files which showed that a thorough staff recruitment process is followed at Holly House. Job candidates fill in application forms, their employment history is checked and two satisfactory references are obtained. People have POVA and Criminal Records Bureau checks before taking up their post. There were records of induction training, one to ones with the manager. Staff have their performance appraised to make sure any gaps in training are identified and addressed to maintain the skill balance in the home. For nursing staff, there was an up to date schedule of their registration numbers with the Nursing and Midwifery Council. Holly House (Beechley) DS0000047937.V366100.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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Holly House is managed in a way that makes sure it is run in the best interests of people who live there. EVIDENCE: Anne Fitzpatrick was registered with CSCI as manager of Holly House in March 2008. A deputy manager has recently been appointed to support her. The manager has many years nursing and management experience and states her role as follows, “Setting high standards of resident focused care and support and developing evidence based practice within the home. Facilitate a positive culture within the home, encouraging teamwork and provide effective leadership. Inclusion of residents in the development and delivery of the service. Building positive relationships with Local Authority purchasers and healthcare professionals”. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 23 Two members of staff were spoken with and they said the manager is approachable and supports them well. There is a quality assurance system in the home which is based on seeking the views of people who live there and their families through distribution of surveys. This means that people can say what is important to them and have a say in how their home is run. Senior managers of the organisation that runs the home carry out regular visits to the home to monitor the standards and make arrangements to address any shortfalls in service. A series of health and safety checks is carried out by staff and qualified engineers as appropriate to make sure the building is safe and suitable to live and work in. The certificates for safety checks was seen and were all up to date. Staff are provided with relevant training and given information and guidance on safe working practices. We looked at the accident book which gives evidence that there are procedures for recording accidents and incidents in the home. In this way, personal risks can be identified and remedial action taken to avoid future occurrences. We spoke with staff and looked at care plans which gave evidence that there are systems for the safe moving and handling of people who live in the home and staff have received relevant training. Holly House (Beechley) DS0000047937.V366100.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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 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 3 X Holly House (Beechley) DS0000047937.V366100.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. Standard Regulation Requirement Timescale for action 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 YA24 Good Practice Recommendations It is recommended that work to set up a residents’ laundry be given priority, as this will help to develop people’s independence and skills. Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Region Unit 1, 3rd Floor Tustin Court Port Way 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 Holly House (Beechley) DS0000047937.V366100.R01.S.doc Version 5.2 Page 27 - 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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