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Care Home: Holywell Care Services

  • Holywell Home 17 West End Road Morcambe Lancashire LA4 4DY
  • Tel: 01524811418
  • Fax:

Holywell is a care home providing personal care and accommodation for up to 6 adults with a learning disability. Holywell is a large terraced house situated at the West End of Morecambe, close to the promenade, with easy access to all the amenities. There are two communal lounges, one on the lower ground floor, which is the one most residents prefer, and one on the first floor, which also has a pool table and darts board as well as a television, for the residents` enjoyment. There is a kitchen/diner on the lower ground floor. There are two communal bathrooms and toilets. All the bedrooms are for single occupancy. There is no lift and therefore the home is not suitable for people with a physical disability. Current weekly fees are between £361 and £571, and the residents pay for additional extras such as hairdressing, outings and holidays.

  • Latitude: 54.067001342773
    Longitude: -2.8740000724792
  • Manager: Mrs Judith White
  • Price p/w: £466
  • UK
  • Total Capacity: 6
  • Type: Care home only
  • Provider: Connor Associates Ltd
  • Ownership: Private
  • Care Home ID: 8526
Residents Needs:
Learning disability

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for Holywell Care Services.

CARE HOME ADULTS 18-65 Holywell Care Services Holywell Home 17 West End Road Morcambe Lancashire LA4 4DY Lead Inspector Ms Jenny Hughes Key Unannounced Inspection 12th August 2008 10:00 Holywell Care Services DS0000071047.V370374.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 Holywell Care Services DS0000071047.V370374.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. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holywell Care Services Address Holywell Home 17 West End Road Morcambe Lancashire LA4 4DY 01524 811418 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) robert.connor@holywell-care.org Connor Associates Ltd Manager post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To people of the following gender: Either: Whose primary car needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of people who can be accommodated is 6 Date of last inspection This is the first inspection of this service under the new provider Brief Description of the Service: Holywell is a care home providing personal care and accommodation for up to 6 adults with a learning disability. Holywell is a large terraced house situated at the West End of Morecambe, close to the promenade, with easy access to all the amenities. There are two communal lounges, one on the lower ground floor, which is the one most residents prefer, and one on the first floor, which also has a pool table and darts board as well as a television, for the residents’ enjoyment. There is a kitchen/diner on the lower ground floor. There are two communal bathrooms and toilets. All the bedrooms are for single occupancy. There is no lift and therefore the home is not suitable for people with a physical disability. Current weekly fees are between £361 and £571, and the residents pay for additional extras such as hairdressing, outings and holidays. Holywell Care Services DS0000071047.V370374.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 that the people who use this service experience good quality outcomes. This was an unannounced visit to the home, meaning that the owner, acting manager or staff did not know that the visit was to take place. This site visit was part of the key inspection of the home. A key inspection takes place over a period of time, and involves gathering and analysing written information, as well as visiting the home. During the visit we (Commission for Social Care Inspection) spent time speaking to residents, staff, the acting manager and the owner. Every year the registered person is asked to provide us with written information about the quality of the service they provide, and to make an assessment of the quality of their service. It also asks about the registered person’s own ideas for improving the service provided. We use this information, in part, to focus our assessment activity. Surveys were sent and received from residents and staff from the home. During the site visit, staff records and resident care records were viewed, alongside the policies and procedures of the home. We also carried out a tour of the home, looking at both private and communal areas. Everyone was friendly and cooperative during the visit. What the service does well: The home provides good information about the home for prospective residents and their families, which is also available in formats that may be easier to understand if necessary. There are systems in place whereby the management of the home would carry out a thorough assessment of need of a prospective resident before they moved into the home. The individual would also visit the home to make sure it was the best place for them, and they liked it. Assessments are all based on each individual’s different needs, to make sure the right care and support is given to each person. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 6 We saw that the information held by the home creates a clear mental picture of the person and how to best care for them. The information the owner sent us said “Our plans are to create opportunities for residents to achieve their potential in accordance with their changing needs and preferences.” Comments made by the residents on surveys, and written by staff due to residents’ needs, included, “You help me. Always look after me. Not going to tell lies”. And regarding whether staff are available at all times, comments were, “There’s always someone” and “Always someone to speak to when you come in”. Staff said they have noticed, particularly with residents who are able to communicate well, that they have realised the freedom they have in being able to have choices and make decisions about their lives, and are very stimulated with this. “We promote independence, choice and social inclusion and rights”, said one staff. We saw the staff going about their work always having time to talk to residents who had questions to ask, and involving all of the residents in what was happening in the home. We saw one resident engrossed in a computer, another helping to prepare the lunch, while another was going with a member of staff to have a look at a possible job opening. Residents were seen to come and go to their rooms as they wish, some choosing to stay there for a while to watch television or play music, or just spend time on their own. The home is warm, comfortable and clean, and the owner told us of the plans to refurbish and update the whole of the building. We noted that regular services to all household appliances and equipment were up to date. 50 of the staff hold a National Vocational Qualification (NVQ). There is good communication within the staff team. All of the systems in the home are being updated so as to be more structured, with complete and easy to find records. What has improved since the last inspection? What they could do better: The recruitment procedures of the home must always be followed, and full checks received prior to the person starting working at the home. We confirmed the legislation with the owner who had misunderstood the guidance. All staff must be in possession of an enhanced CRB (Criminal Records Bureau) disclosure prior to starting work. In exceptional circumstances, such as extreme staff shortages, people can start to work on the receipt of a clear POVA 1st check (Protection of Vulnerable Adults), while waiting for the full clear CRB disclosure. During this time they must be supervised at all times. This Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 7 must not be a routine procedure, and the CRB disclosure is the full requirement. There are some places and furnishings in the home that are looking tired and worn, and the owner discussed their plans to refurbish and update the environment. The progress will be identified at the next inspection. Staff were seen carrying out tasks following infection control procedures, making sure residents were protected from infection and toxins. However there was no Infection Control Policy and written procedures in place to inform staff of what was expected of them. This policy needs to be developed. Any information regarding changes in the administration of medication for a person needs to be included on the Medication Administration Record (MAR), rather than on an additional note attached to it. As the owner does not plan to manage the home on a day-to-day basis in the future, a manager needs to be appointed and registered with the Commission for Social Care Inspection. 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. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 8 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 Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 9 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): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No resident moves into the home before having their needs and aspirations assessed and being assured that these will be met. EVIDENCE: There is detailed information available about the home for all residents, or possible residents, which provides an easy to read description of the services provided, and who provides them. It is available in written and pictorial format, which is used to help the reader understand the content. “Somebody recommended me to this house” was a comment from a resident. We selected two residents to case track, where we examined the individual assessments and care of those people from admission to this home, to present day. There have been no new admissions since the new owner has been running the home, and she is in the process of reviewing procedures to make sure they are up to date and produce relevant information. We saw that individual records were kept for each resident, and the staff discussed the way anyone new would be initially invited to visit the home and Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 10 meet the residents. We noted that a social work assessment is used to help the owner decide whether the home was the right place for the new person. The new owner, with the staff and the residents, has reviewed the needs of all of the residents to ensure the information held is completely up to date, and each person’s individual aspirations are being addressed. We saw the clear and detailed information on each file we looked at. There was information on the residents’ strengths, needs, personal goals, and choices on how they wanted their support to be provided. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 11 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): Standards 6, 7, and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to make decisions in their lives meaning that individual needs and choices are met EVIDENCE: We saw that each individual’s plan told staff how to best look after them, giving information which includes areas covering their physical and mental health needs, dietary needs, and a personal profile. We saw that the owner is reviewing the systems used so that they are more structured and easy to keep updated and person centred. We saw that daily records are made for each person by staff. These produce a full picture of people’s lives, giving evidence of the constant care provided, and background information for any future incidents. Residents are supported to make their own decisions about their lives. One resident was supported to try and achieve success in a new job because that’s Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 12 what they wanted to do. We saw another getting their own money out of a locked cupboard because they wanted to shop. This was monitored and recorded by staff. Surveys returned from residents all said that they received the care and support they need. Staff are encouraged by the new owner to motivate residents to do things for themselves, and to make decisions on how to do them, rather than be ‘looked after’ totally by staff. The staff said that the residents were gently guided to help them make their own decisions, and risk assessments are carried out on residents’ activities. One resident was helping to make the lunch, and was encouraged to decide how to prepare things herself. She proudly showed us the results of her work, which were contribution to a salad, and a fish pie for the freezer, both well presented. Staff were subtly present, monitoring and encouraging residents in this lively house. We noted that all staff and residents in this house worked together with no barriers. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s decisions are respected and daily routines promote independence. EVIDENCE: The owner stated in the information they sent to us that “Several residents have shown signs of changing their lifestyle by taking up new activities such as, employment, education and social activities (going to the cinema, swimming and cycling). All staff accept the benefits of supporting residents to take acceptable risks so that they can achieve better outcomes and lead richer and more fulfilling lives.” We saw one resident retrieve his own information from a locker to take with him to a garden centre, where he was going with a staff member to see if he would like to work there. Another resident was happily working on a computer, which had been placed where she could be mostly undisturbed, but still see Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 14 what was going on in the home, and another was helping to prepare lunch and set tables. “I like doing keep fit”, said one resident, “and swimming”. Comments made on resident’s surveys about activities were, “I go to work. And to college”, “Last year we went swimming”, “Watch DVD’s. Sometimes watch thrillers”, “See my family” and “I go out with a member of staff. I go out on my own as well. I’m getting a job somewhere”. Residents are enabled and supported in their relationships with other people. Residents tucked into their lunch at the dining table in the large dining kitchen, where they chatted as they ate. We saw a weekly record of the meal plan showing clearly what food had been eaten. The residents said that staff always ask them what they’d like to eat. The general opinion from the surveys was that the meals were liked at the home, “Some meals I like but some I don’t”, “I do like food”, “Meals are always good” and “I like curry”. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 15 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): Standards 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the residents’ support needs. The medication at this home is well managed, promoting good health. EVIDENCE: All residents have a Health Action Plan (HAP), which is in the form of a booklet which holds all the information about the health and welfare of the residents, for example noting when there have been visits to the doctor or dentist, and what for, and when the next visit is due. It notes their choices on how they like things done. Residents can choose whether they keep their HAP in their own locker, or whether they want staff to keep it in their file. We saw one resident who had returned from a visit to the doctor with a staff member. Staff asked about her experience and listened as the resident explained what had happened and what the problem was. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 16 We saw medication records, which were clear and up to date. We advised any changes in prescribed medication to be noted and signed on the Medication Administration Record (MAR) and not just on a separate paper. There is a system where all residents have a risk assessment before it is decided whether it is safe for them to be in charge of their own medication, or whether care staff take control of administering the medication. Any ‘over the counter’ medication was listed and instructions given for administration. Staff helping with the administration of medication had attended a medication awareness course. No controlled drugs were being used, but the person in charge was aware of storage requirements. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 17 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): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident their concerns will be listened to and acted upon. Staff have an understanding of Safeguarding issues, which protect residents from abuse EVIDENCE: We saw that there is a complaints procedure in place, with a complaints book to record any complaints, which may come to the manager’s attention. There have been no complaints since the last visit. The owner told us “Residents are fully familiar with the policy that encourages open discussion of any complaint or concern that they may have.” Residents responded when asked if they knew how to complain, “Yes I do” and “I’d come to you (staff) if I wasn’t happy”. Staff said that they would note any changes in mood of residents, which would indicate that they were not happy about something, and would try to find out what it was and put it right. Staff spoken to knew about the Safeguarding Adults procedure, and what to do if they had any concerns. They understood about whistle-blowing procedures, whereby staff are encouraged to report if they suspect abuse may be taking place. Holywell Care Services DS0000071047.V370374.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment. EVIDENCE: The owner stated in her information to us “Plans are being developed to refurbish the home and upgrade the facilities.” We saw that the home is warm, comfortable, and clean, but there are places around the building that are worn and need maintaining, refreshing and generally improving. The ongoing refurbishment plans mean that the standard will improve and be maintained at a higher level. There is a lounge on the upper floor, which is used as a games room, with a pool table and darts board ready to use. Sofas and a television make it comfortable, although wallpaper is badly peeling from the wall. The lounge on the lower floor is the one most often used, and the one through which visitors Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 19 to the home walk, as the entrance door is on one side of it. This also has poor wall coverings, and a tired and worn sofa and chairs. The owner told us of plans to buy new seating, and address the flooring also. The residents’ bedrooms are all nicely furnished, clean and personalised with whatever the residents wish to have in their rooms. Residents surveys all stated that they thought the home was clean, commenting, “It’s spotless”, “We’ve got a girl who comes to clean our bedrooms. She cleans the bathrooms nicely as well” and “Always nice and clean”. Presently, residents need to be mobile as there is no lift to assist with moving between floors of the home. The owner discussed plans to possibly have a lift installed in the future. The needs of all the present residents are met. There is an outside paved area to the rear of the property, with seating and planters, to make it a pleasant place to sit in the better weather. Fire and environmental health checks have been carried out. The information provided from the home stated that there is no formal Infection Control policy, and this needs to be addressed. We saw staff carry out tasks following infection control procedures. Holywell Care Services DS0000071047.V370374.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): Standards 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a good recruitment policy, which if followed correctly ensures that only people who are suitable for this type of work are offered an appointment. Training is provided and this means that residents are provided with appropriate care and attention EVIDENCE: We selected the files of two recently recruited staff. We saw that there are standard recruitment procedures, with references from past employers, and Criminal Records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) checks having been applied for. One new staff had started employment before their CRB disclosure, and POVA check, had been returned to the home. In discussion with the owner we discovered that she had misunderstood the legislation, and we confirmed that all staff must be in possession of an enhanced CRB disclosure prior to starting work. In exceptional circumstances, such as extreme staff shortages, people can start to work on the receipt of a clear POVA 1st check, while waiting for the Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 21 full clear CRB disclosure. During this time they must be supervised at all times. This must not be a routine procedure, and the CRB disclosure is the full requirement. This staff member was taken off the rota until satisfactory disclosures have been received by the home. The home held satisfactory disclosures for the other staff. We saw that residents took part in the recruitment of staff, and were able to give their opinions on the new applicant, and their comments were recorded. We saw the staffing rota, and the owner confirmed the long-standing rota had allowed for only one staff on duty in the evenings. Residents were developing a fuller social life and were becoming more active in the evening, so recruitment was ongoing with a view to increasing the evening staff numbers to accommodate this. “We are recruiting at the moment to have more staff in the evenings so that residents can also have a night life” said a staff member. The owner had recognised this in her information sent to us, “We could do with more staff for effective support for individual needs.” All staff attend induction training when starting work at the home following Skills for Care guidelines. One staff said this training made her feel confident to do the work. We saw that 50 of the care staff had NVQ qualifications, with the rest working towards it. Training has been attended in Fire awareness, health and safety, medication awareness, first aid, and food hygiene. Further training is being obtained through the Lancashire Workforce Development Partnership, and through specialist providers, such as Beaumont College. Comments on staff surveys included; “I have already seen the difference under the new management. We now have a staff training programme and we can all attend training courses that we are not just needed to have, but that could be relevant in the future”, and “ I have NVQ Levels 2 and 3, and I have attended numerous courses, including Person Centred Planning, and if I feel I need more support I know I can ask the owners” Staff have formal supervision and appraisals, with a performance review. Staff meetings have taken place, and we saw minutes, which noted discussions on residents’ care, training, tasks in the home, and confidentiality. Holywell Care Services DS0000071047.V370374.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): Standards 37,39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home that is well managed and where their health, safety and welfare are of paramount importance EVIDENCE: There is no manager at present who is registered with the CSCI, and until one is in post, the owner is responsible for the running of the home. The owner has good experience of working with people with learning difficulties, and has a social work background. Senior staff who work in the home are long term and hold NVQ qualifications. The owner said that they wanted the residents to develop their independence as much as possible. She commented that resident meetings also gave them a Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 23 ‘voice’, and we saw the minutes of these meetings. These showed areas raised at one meeting, including; staff asking permission to enter residents’ rooms to help maintain them; residents were invited to help interview new staff; a discussion on holidays and where residents wanted to go; a discussion on the new time for tea which they much preferred; excitement about their new lockers where they could store valuables and bank books; opinions were asked for regarding new decoration in the home. The residents were all relaxed and choosing to do whatever they wanted, clearly telling or signalling the staff about what they did not want to do. This ongoing feedback is dealt with immediately, and recorded for future reference. Staff were aware of residents who had communication difficulties, and how they may need extra support to deal with more vocal residents. Residents have been enabled to have greater control of their finances, and one resident was seen getting his own money out of his locked cupboard, using his own key. Staff monitor the process and records are signed. All of the residents have their own bank accounts and bankbooks. Staff support residents in drawing money out from their bank accounts. The systems used in the home are being gradually updated. Records are easy to find and well structured. All accidents are recorded on file. Appropriate fire precautions are taken using a fire alarm system, and extinguishers, all of which are checked regularly. All staff are instructed on what to do in case of fire, with regular fire drills. Holywell Care Services DS0000071047.V370374.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 X 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 2 35 3 36 X 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 3 X 3 X Holywell Care Services DS0000071047.V370374.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 YA34 Regulation 19(1)(b) Requirement Timescale for action 12/08/08 2 YA37 A person must not be employed at the home unless the information as stated in Schedule 2 of the Care Homes Regulations 2001 has been received. 8(1)(b)(iii) A manager must be appointed and registered with CSCI 30/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. Refer to Standard YA20 YA24 YA40 Good Practice Recommendations Changes to information relating to medication administration should be on the MAR sheet and signed. The refurbishment of the home should continue to make sure it is safe and well maintained. There should be an Infection Control Policy and Procedures in place to ensure the protection of each individual’s health and welfare. Holywell Care Services DS0000071047.V370374.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Region CSCI Preston Unit 1 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 Holywell Care Services DS0000071047.V370374.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. 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Holywell Care Services 12/08/08

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