Care Home: Hollycroft

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What the care home does well The home is a relaxing and homely environment that suits the needs of the people living there. The people can continue living the life they choose, participating in daily social, and leisure and work routines with support from staff when required. The home had made appropriate arrangements for the people who use the service to contact and visit family. There was evidence that the home supported people who use the service to maintain family links and friendships inside and outside the home. The staff and the people using services have good working relationship; this was observed during the inspection process. The home had developed a robust quality assurance system and procedures which included regulation 26 visits as well, to oversee the quality of care provided by the home in the best interest of the people using the services at the home. What has improved since the last inspection? The manager is now registered with the commission. The registered manager had made appropriate efforts to meet the outstanding requirements from the previous inspection report. The home was in the process of introducing computer based new care planning and delivery system called SPARS, which is scheduled to go online by December 2008. Risk assessments and care planning process and documentation has improved in the last couple of months, to enable the staff working with people using services to provide appropriate and timely care. People who use the service are encouraged to personalise their bedrooms, with the support from family and staff if required. What the care home could do better: Staff must be provided with suitable facilities for the purpose of changing & sleeping accommodation. The registered manager must ensure that the service has adequate number of staff with NVQ level 2 or above qualification. Disposable hand towels should be provided in communal toilets and bathrooms, to ensure effective infection control practices are not compromised. CARE HOME ADULTS 18-65 Hollycroft Hollycroft 90 Church Street Langford Bedfordshire SG18 9QA Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 11th June 2008 12:15 Hollycroft DS0000014915.V364483.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 Hollycroft DS0000014915.V364483.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. Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollycroft Address Hollycroft 90 Church Street Langford Bedfordshire SG18 9QA 01462 701273 01462 850689 julia.keens@hft.org.uk www.hft.org.uk Home Farm Trust 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) Julia Kathleen Keens Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2007 Brief Description of the Service: Holly croft is a large detached house in the village of Langford that has been adapted to provide accommodation for eight adults with learning disabilities. The house was situated in the main street of the village and there were pubs, church, and shops in close proximity. There was an infrequent bus service to the nearby town and the home had two domestic style vehicles for the use of the people living at the home. The adaptations to the house resulted in six single rooms on the first floor with two bathrooms and a separate toilet and staff accommodation. Two further bedrooms were provided on the ground floor with a bathroom, separate toilets, two lounges, dining room, and kitchen. A laundry room was provided on the ground floor but access to this was from the garden. The large rear garden was enclosed and overlooked open fields. To the front and side of the building was parking space for five or six vehicles but some manoeuvrability was required if the parking space was full. The weekly fee ranged from £513 to £530.20. Hollycroft DS0000014915.V364483.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 2 star. This means the people who use this service experience good quality outcomes. This is the report of the unannounced inspection carried out on 11th June 2008 by Pursotamraj Hirekar over 6 hours 35 minutes. The registered manager coordinated the inspection; deputy service manager partly supported the process. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, staff profiles, relevant care delivery documents, discussions with staff and people using services, observations of staff and people using services interaction and partial tour of the building. Annual quality assurance assessment (AQAA) – provider’s self-assessment received from the registered manager is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? The manager is now registered with the commission. The registered manager had made appropriate efforts to meet the outstanding requirements from the previous inspection report. The home was in the process of introducing computer based new care planning and delivery system called SPARS, which is scheduled to go online by December 2008. Risk assessments and care planning process and documentation has improved in the last couple of months, to enable the staff working with people using services to provide appropriate and timely care. People who use the service are encouraged to personalise their bedrooms, with the support from family and staff if required. Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 6 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. Hollycroft DS0000014915.V364483.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 Hollycroft DS0000014915.V364483.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 quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service receive information about the home, and are involved in the assessment process to ensure their needs are met. EVIDENCE: Information about Hollycroft is contained in the statement of purpose and that was comprehensive and reflects the current services, offered to prospective and existing service users. The process for moving into the home, facilities, and choices is detailed including the complaints process. The information set out, is in an easy read style, to suit the communication needs of the people using the service. This is given to people when they move to the home as part of the admission process. There has been no new admission to the service since the last inspection. Therefore this standard could not be fully assessed. However 2 people using the service were case tracked. The home had undertaken a full assessment of needs for each of them. The needs assessment was also supported by a health and social services assessment. The method of assessment involved the person who used the service, the family, and other key stakeholders. There Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 9 was also evidence that the home had regularly reviewed the assessments of need. The home was able to demonstrate that it could meet the assessed needs of people staying at the home. Staff individually and collectively demonstrated that they had the skills and experience to deliver the service and care which the home said it could provide. Staff were observed communicating with people using the service in different forms of communication to suit their individual preferences and needs. There was evidence that the people who used the service whose lives were tracked had written contracts with the home. This included a statement of the terms and conditions, which had been signed by them or their representative, and the manager. There was evidence that the home had introduced contracts in a format appropriate for the needs of the people who use the service. Hollycroft DS0000014915.V364483.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 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home had developed detailed care plans based on the needs and risk assessments of the people who use the service to support all aspects of their lives. EVIDENCE: The care documents of 2 people using the service were seen. The person centred plan outlined the individual need with regard to their personal care needs, support, health care, daily routines, domestic tasks, communication, transport, cultural issues, finances, social interests and risk assessments. The information was holistic and from the view of the people using the service in relation to their choice of lifestyle, needs and interests. Information was written to help staff to provide the right level of support in relation to promoting independence and skills for daily living such as personal care, domestic tasks, and accessing the community. People using the service Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 11 said staff knew their routines and choices. The daily routines presented in the person centred plans reflected in the daily reports of the people using the services. The care plans were presented in an appropriate format to read and understand by the people using the service with communication needs. Also the care plans could demonstrate how the family members were engaged in the care planning and review process. Person centred plans were reviewed annually or as and when the need arouse and the changes reflected in the care plan. For example guidelines were prepared to ensure a person’s personal care needs, road safety and improving self-confidence. And for another person, guidelines were prepared for independent travel to college. The staffs working were aware of the changes to the care plan of the person. In the annual care plan review people using the service, their family, key worker, manager, and other key stakeholders have participated. The review covered actions from previous meetings, support needs, daily activities, hobbies and interests, friends and family, cultural and faith issues, money, communication and health. The areas covered in the review meeting could ensure that a person’s quality of life goals were being met. The care plan folder covered various documents some that are old and others current, this made the folders difficult to use as some important papers were falling out. This was the case with the 2 people who were case tracked. However, the folders of other people were better arranged. This was discussed with the registered manager, who said the service was in the process of computerising all the information using the new care planning, care review and care delivery information recording software system called SPARS, that is expected to go live in December 2008. By which times there would very few papers on the current folder, for each person using the service. People using the services can access social and community activities locally, which include their daily routines; going to their place of work or day centre either independently or transport arranged and shopping. Observations made indicated the relationship between people using the services and staff is relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. The staff on duty said people make their own decisions or are supported through conversation to make their own decisions. For example, a staff member and 2 people using the service went out for shopping today, and appeared relaxed on their return. Hollycroft DS0000014915.V364483.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 quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service experience and enjoy a lifestyle that suits them, being part of the community and having meals of their choice. EVIDENCE: Staff said people moving to the home are supported to continue participating in daily social and community activities. Information about individual daily, social and community activities are detailed in the assessment and included in their care plan. The people using the services, confirmed during the discussion that they continued to participate in daily activities ranging from the day services, college, going out socially with family and friends. People can choose how to spend the evening and weekends, ranging from seeing friends and family and watching television or films. Activities and daily routines were reflected in the Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 13 daily records and consistent with the interests recorded in the individual care plans and have also matched with today’s activity plan. People using the services indicated, they felt in control of their life at the home and were not restricted in what they did. For example, 2 people using the service with a staff member planned and concluded weekly shopping, one person had his hair done, and another was busy using the computer Internet that was specifically made available for the people using the service. Another person was enjoying playing with toys, and at times with the assistance of a staff member. There was evidence that the home supported people who used the service to maintain family links and friendships inside and outside the home, in accordance with their wishes. People who were spoken with, who lived at the home, and who said that their families and friends could visit at any time supported this evidence. Staff demonstrated a good understanding of the people they key work, recognising if the person is anxious or unhappy, and how to approach them. People using the service spoken to, have said that they have the freedom to make choice of the meals and mealtime. Staffs have received training in preparation and safe handling of food. Staff said they always encourage the people to choose the meals, offering fresh fruit and vegetables. Hollycroft DS0000014915.V364483.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 quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The personal and health care needs of people who use the service, are met promoting their independence and quality of life. EVIDENCE: The personal and health care needs of the people using the services are detailed in their individuals’ health care plans, which were presented in a pictorial format, and staff have guidance in relation to the level of support required, if any. Risk assessments are detailed and to include information about personal care, personal hygiene, toileting, medication, and technical aids, domestic tasks, social, and day care activities. The registered manager, staff, and the people who use the service had good working relationships. This was supported through the observations made during the interactions, and the people who were using the service, who said, they enjoyed living at the home. Records viewed suggested people who used the service received personal support in the way they preferred and most were encouraged to maximise their independence. Each person who used the Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 15 service had a key worker, who they were each able to identify and those people who used the service that were spoken with, said they were happy with the support from them. The people using the service said they were not restricted to continue living their lifestyle of their choosing. The home had made arrangements for the people using the service to maintain contact with family and friends. Care plans detailed emergency contacts and health care professionals involved in their care. The records showed people had regular appointments with the general practitioner, dentist, chiropodist, physiotherapist, psychologist, and opticians. One person was waiting for the chiropodist to come in the evening. The staff were supporting 2 people to become independent in self-medication; currently the staff provide close supervision whilst medication is being selfadministered. Trained staff are administering all other people medication, staff training records, and staff spoken to have confirmed this. The staff on duty demonstrated a good understanding of the medication, people using services take and the importance of having the medication on time. People said they do receive their medication on time. Medication is stored in a locked cabinet with the medication records. The medication for two people using the service was checked, which was consistent with the medication records. The staffs administering the medication have followed PRN medication guidelines, as and when they administer PRN medicine. Hollycroft DS0000014915.V364483.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 quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. Staffs are trained and people who use the service their interests are protected by procedures and practices including handling of money. EVIDENCE: The complaints procedure was available in an easy read style for the benefit of people using services that have communication needs. The people using the services indicated that they were informed of the process how to make a complaint or express concerns about the provision of care provided at the service. A person said, she had not experienced any problems or had any concerns about living at the home. Another person said if, “I am not happy, I just speak with the manager or my key worker”. The service has had no complaints received since the previous inspection and commission had also not received any concerns, complaints, or allegations about the service. The service had arranged for staff training on safeguarding, the staff on duty, demonstrated an adequate awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. Staff were confident to whistle-blow poor on bad practice and confirmed that the registered manager is available should any concerns arise. Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 17 The people using the service can choose to manage their own money if they are able to do so. Records of money transaction were maintained. The registered manager described the process for recording and handling of money for people using services, which ensures the money, is protected. Any 2 authorised staff members are required, to access the people who use the service, their money, and records. The money transaction records and the balances were checked for 2 people, and found to be correct. Hollycroft DS0000014915.V364483.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, 28 & 30 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service live in a warm, clean and a homely environment. However, further development was needed to improve staff changing and sleeping facilities. EVIDENCE: The home was clean and tidy without any offensive odours and in appearance that suits the lifestyle of the people living there. The lounge/dining room decorated and furnished with domestic furniture that compliments the décor. There is good lighting throughout the home. Individual bedrooms were personalised to suit the choice and taste of the people who use the service. The bedrooms are appropriately furnished and include personal objects as well. One person showed us her bedroom, which Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 19 had been personalised with photographs and toys that reflected her interests and hobbies. The people who use the service appeared to be at ease in the home with the staff on duty, choosing to sit in the lounge or going to their bedroom. Information received from the registered manager prior to the inspection stated that the home has a rolling programme of maintenance and decoration of the bedrooms and communal areas. Comparing the premises maintenance meeting record with the actual action taken supported this statement. For example, one person’s bedroom roof had been leaking, this was repaired and decorated, the person spoken to have said, she is happy with her bedroom. The service had carried out fire safety annual audit on the 17/01/08 and follow up meetings were held with fire authorities, the records seen on this inspection supported this information. Checks have been carried out regarding emergency lights, fire equipment, fire alarm, fire escape routes, fire drills, and hot water temperatures. The latest, health and safety meeting with the staff was held on the 28/02/08, to ensure, that the staff were following all the appropriate procedures to maintain, a service free from environmental hazards. As reported in the previous inspection report that, staff were provided with unsuitable sleeping and changing facilities when sleeping in, as their sleeping in facilities also became the combined and integrated office for the home and where the manager was based. This arrangement was clearly unsuitable as there was insufficient room for this to be practical and consequently people had no alternative but to sit on the bed as there may be no other suitable alternative available. The management is aware of this situation and has made arrangements for the extension of the property with adequate provisions for the staff room. The service had received the planning permission on the 28/04/08 for extension of the property. The pre - construction work was in progress. It was reported in the previous inspection report that, further development was needed to improve infection control practices in some areas of communal toilets and bathrooms. This practice continued as on this inspection. When asked, the registered manager said that, the home has carried out risk assessments and that there has been no incidence of cross infection as such, in relation to the bath mats and communal towel usage by the people using the service. Also, the staffs on duty are particular that they ensure people who use the service, have a proper hand wash before eating. However, the registered manager agreed to revisit, the potential situation of cross infection, from a preventative point of view and put in appropriate measures in place. Hollycroft DS0000014915.V364483.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 & 36 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The people who use the service are protected by staff recruitment procedures, and supervision. However, further improvement was needed to meet the required percentage of NVQ level 2 qualifications of staff. EVIDENCE: The interaction of staff with the people using the service was good; there was good rapport, both verbal and non-verbal communication was used. The key worker was aware of the needs of the person’s routines and how best to communicate with them. The home had a good recruitment procedure and practices in place. 3 new staff recruitment records were seen and found that, staff appointed upon receipt of an application, two satisfactory references, and Criminal Records Bureau (CRB) check. Staff training records showed that staffs have received induction training, safeguarding, person centred planning, medication, health & safety, COSHH, Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 21 manual handling, dementia care and fire hazard. This was supported by staff spoken to, which identified varied training, which they had undertaken. Staff NVQ level 2 or above is much below the requirement of 50 . This was supported by the information received from the registered manager through the annual quality assurance assessment – AQAA. This situation has arisen, due to the recruitment of new staff members’ since the previous inspection. The management was aware of this situation, and was waiting for the new staffs to complete their probation period prior to their enrolment for NVQ level 2 or above qualification. The service had maintained appropriate staff deployment ratio based upon the needs of the people who use this service. Staff on duty, confirmed they received supervision. In the staff supervision, concerns raised by staff are addressed in the best possible way, which benefits the people using the service. Hollycroft DS0000014915.V364483.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 quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home has good quality assurance systems and procedures that enable the management to run a well managed home, to promote the quality of life of the people who use the service. EVIDENCE: The service now has a registered manager. The registered manager appeared to have developed good working relations with the staffs and the people using the service. Observation made indicated that, she was approachable and polite in her interactions with the people using the service and staff. The various care documents seen on this inspection confirmed that there are clear roles and responsibilities in relation to the management of the home and Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 23 staffing. Staff meetings were held, to discuss people’s assessed needs and care delivery, to ensure people who use the service their assessed needs and staff training needs were being met. The staffs spoken to were confident that registered manager would be available if there was an emergency. All policies and procedures are updated, reviewed, and shared with the staff. The home had presented the quality assurance system and procedure, which appeared robust. The quality reviews undertaken in October and December 2007, January and February 2008 and the regulation26 visit report for the April 2008 was seen and found that the service had been actively engaged in quality assurance work, to ensure that the people living at the service, their quality of life goals were met. The home had health and safety monthly checks carried out, these checks help in identifying any concerns to the premises; for example the checks carried out on 11/02/08 noted, a person’s bedroom roof required decoration following shower leaking upstairs. The bedroom roof has been repaired and decorated to the satisfaction of the person living in. The person using the room had shown the inspector, where exactly the roof was damaged and repaired. The people using services, spoken to confirm that, they are encouraged to express themselves about the running of the home, what improvements are made in relation to their accommodation, décor and they can speak with staff at anytime. Hollycroft DS0000014915.V364483.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 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 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 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 Hollycroft DS0000014915.V364483.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001, and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 18 (1) Requirement The registered manager must ensure that the service has adequate number of staff with NVQ level 2 or above qualification. Staff must be provided with suitable facilities for the purpose of changing & sleeping accommodation, as staff in connection with their work at the home needs this. Previous time scale (31/08/07) Time extended as the work was in progress. Timescale for action 30/08/08 2. YA28 23 (3) (b) 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 7. Refer to Standard YA30 Good Practice Recommendations Disposable hand towels should be provided in communal toilets and bathrooms, to ensure effective infection control practices are not compromised. DS0000014915.V364483.R01.S.doc Version 5.2 Page 26 Hollycroft Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Hollycroft DS0000014915.V364483.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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