Care Home: The Hollies

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What the care home does well The information made available to people living at the home, or those who might wish to in the future is easy to understand, and provides a good introduction and description to the home. The in-house activities organised by the staff are varied, and imaginative, with a real attempt to include everyone who lives at the home. There is good use of local facilities in the community, and people living at The Hollies are encouraged to make use of those facilities, and become involved in the wider community. People who live at the care home are safe. The building is very comfortable, and has good facilities for those people who might have restricted mobility, while also looking to maximise people`s independence. What has improved since the last inspection? A new flat has been developed, primarily for use by people who are on a rehabilitation programme. A number of areas of the building have been redecorated. Several new carpets have been laid around the building. New non-slip flooring has been laid. Activities have improved, with a daily activity at 3:00pm. A new `meet and greet` format for ensuring new people moving into the home have the information they require has been introduced. What the care home could do better: No statutory requirements or good practice recommendations have been made as a result of this key inspection. CARE HOME ADULTS 18-65 The Hollies The Hamlet South Normanton Derby DE55 2JN Lead Inspector Rob Cooper Unannounced Inspection 10th December 2008 09:50 The Hollies DS0000020018.V373420.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 The Hollies DS0000020018.V373420.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. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address The Hamlet South Normanton Derby DE55 2JN 01773 580872 01773 580872 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Mikayla Pawley Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is 23 11th August 2006 2. Date of last inspection Brief Description of the Service: The Hollies is a purpose built care home set in its own landscaped garden. The home is not close to shopping areas but is a short bus ride from Alfreton, which offers a good range of facilities. The home provides accommodation for 23 younger adults with mental health needs. The Hollies provides staffed care, full board and a range of social and leisure activities. Service users have access to laundry and kitchenette facilities to promote independent living skills. The current scales of charges at the home per week are: £405- £700. Further information regarding the Hollies can be obtained by telephoning the registered manager. The Hollies DS0000020018.V373420.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 3 stars. This means the people who use this service experience excellent quality outcomes. This was an unannounced visit as part of the key inspection process – so that no one at The Hollies knew that the inspection visit was going to take place. The visit took approximately six hours through the middle of the day, with one inspector present. In preparing for this inspection, the information that the Commission holds about this care home was reviewed, this included looking at the last inspection report, the inspection record, considering any complaints or concerns that have been made about the service, and reviewing any notifications made relating to incidents that affect the well being of people living at The Hollies. The methods used during this key inspection and visit were to visit The Hollies, where a method called case tracking was used; this involved identifying four people who live at the care home and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour of The Hollies, looking at the activities on offer, and talking to several people who live there, and three members of staff about the quality of the service, and their experiences of living and working at The Hollies. During 2007 the Commission for Social care inspection introduced an Annual Quality Assurance Assessment (known as an AQAA) as part of the inspection methodology; this allows care homes like The Hollies to self assess their service. Information provided by The Hollies helped to form the judgements in this report. We also handed out ten questionnaires asking for views and information, five to people who live at the home, and five to staff. All of the questionnaires were returned, and helped with the judgements that we made. The registered manager Mikayla Pawley provided much of the information during this key inspection visit. On the day of this inspection there were twenty one people living at The Hollies. People who might want to live at The Hollies can obtain information about the home direct from them, and this would include seeing previous inspection reports prepared by the Commission for Social Care Inspection. In addition information about The Hollies and the service it provides can be found at the following web site: www.prime-life.co.uk. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 6 What the service does well: 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 The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. The Hollies DS0000020018.V373420.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 The Hollies DS0000020018.V373420.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): 12&5 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. People had sufficient information before they moved in to make an informed choice about where to live. People living at the home are well informed about the services on offer. EVIDENCE: Both the statement of purpose and service user guide for The Hollies were seen during the inspection visit. These documents contained a great deal of useful information about the care home, and were in an easy read format. The information available would allow people living at the care home, and those who might wish to in the future, to make an informed choice about living at the home. The information pack also contained local information, including a bus timetable, information about joining the local library and information about local activities and places of interest. Discussions with four people who live at the Hollies showed that they had been given copies of the service user guide, and copies were seen in people’s bedrooms. The Hollies identified in their AQAA a new ‘meet and greet’ procedure for new people moving into their care homes, which is a less formal and more user friendly way of ensuring that new people have the information they need: We are introducing a new initiative entitled “Meet & Greet”, a checklist attached to all new residents care plans, to ensure that they are offered meaningful and accurate information, are fully The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 10 informed, in a format that they can understand, and that their introduction to our care centre is overseen by their Key Worker to enable a positive introduction to the service. On the day of the inspection a new person was spending some time at the care home, and the new meet and greet procedure was being used to good effect. As part of the case tracking process four people who live at the care home were identified, and their files were seen, each of the files that were seen contained a formal assessment of need. The assessments had all been completed as part of the application for residency by a Community Psychiatric Nurse (CPN) or a Social Worker, and. In addition there was other background information including social history and risk screening. Each file contained an agreement from Social Services to fund their placement, and a copy of the terms and conditions of residence. The individual had in some cases signed the terms and conditions of residence. In addition people living at The Hollies have a contract with the home around behaviour and expectations are discussed and reviewed on a regular basis. The Hollies DS0000020018.V373420.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): 67&9 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People have their needs assessed, and have an individual plan of care containing information about their needs, and risk assessments to support them in leading an independent lifestyle. EVIDENCE: Each of the files that were seen contained a plan of care, which identified personal goals and identified people’s needs and how to meet them. Evidence was seen that care plans were being reviewed on a monthly basis, and there were daily entries by care staff, to record progress and any issues relating to individual’s care. There was also evidence of individual’s having signed their care plans, to signify their agreement with them. Evidence was seen in several files to support the view that people living at The Hollies are making decisions within their own lives. Specific examples were a The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 12 person who wanted to work in a charity shop, who had been supported to contact them, and put their name down for a job, and another person who had been supported to find a local church, which they now attend independently. The Hollies’ AQAA identifies that individual choice is both encouraged and supported: “We encourage the clients to be as independent as possible and to take control of their lives, to make sure that their lifestyle is purposeful and fulfilling.” All of the files that were seen contained risk assessments, covering a wide range of activities, such as road safety, mobility and medication. Discussions with the manager identified that the risk assessment process was seen as a step on the road to independence, while attempting to ensure that people are safe. Discussions with three members of staff showed that they had an understanding of the risk assessment process, and the role that a risk assessment has in reducing risks, and ultimately keeping people safe. The Hollies DS0000020018.V373420.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): 12 13 15 16 & 17 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. People are offered a stimulating range of activities, and are offered a varied and healthy diet, which means that their social care needs are being met at The Hollies. EVIDENCE: The Hollies have an organised activity every day at 3pm. The activity varies on a daily basis and is organised around an afternoon cup of tea, with details of the activity on display within the home. On the day of the inspection visit, the activity was making Christmas table decorations for the dining room. The majority of the people who live at The Hollies were directly involved in this activity, and the dining room was a hive of activity. The Christmas activity rota showed a wide range of activities arranged for the festive period, and a snowman which had been made at a previous session stood on display in the hall. In fact The Hollies had won a £250 prize in a Prime Life competition (the The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 14 money to be spent on activities) to arrange a Christmas themed activity – they had created an advent calendar, again with staff supporting the people who live at the home in both the development of the idea, and the practical skills in making the calendar. The Christmas cake which had been made, had I was told by the staff been made, with input from everyone who currently lives at The Hollies, this had seen people stirring the mixture, weighing out ingredients, or being involved in the baking. The manager was at pains to stress that this activity was about a joint effort, and everyone being involved. Discussions with three people who live at The Hollies about activities identified that it was not just at Christmas when there were activities organised, and there were all year round activities such as: quizzes, bingo, flower arranging arts and crafts and trips out. The Hollies do have a minibus, which helps in trips wider a field, although as part of people’s rehabilitation, there is a good use of public transport. The home is situated close to local amenities, and the people who live at the home are encouraged to use them. Discussions with three people who live at The Hollies showed that people used the local pub, library, and shops, with one person saying how they go shopping in Alfreton, because it’s better than South Normanton, and they don’t like the local shopping mall at MaCarthur Glen. Further evidence in case files, and in conversations with people at the home showed that people are using local churches, and were quite comfortable travelling on public buses. Unfortunately no relatives were visiting on the day of the inspection visit, so it was not possible to speak with any to get their views. However a visiting Social Worker said: “We are very satisfied customers.” Three people who were spoken with said that their relatives were able to visit, and that the staff made them welcome, and there were no restrictions on visiting times. There is good local contact with the neighbours, including one neighbour who has a common work history with someone living at the home, so the two have been to the pub together, and have a ‘friendly neighbour’ relationship. Offering the people choice is a top priority for the staff, and people living at The Hollies are encouraged to have friendships within the home and outside in the wider community, as social relationships form part of ordinary living. In their AQAA The Hollies said: “We include our clients’ relatives and supporters, both within activities in the care centre, and by assisting clients to return home, we appreciate the importance of family support and positive links.” Discussions with people living at the home showed that there are a variety of different roles that people have taken on. One person waters the plants, another empties the bins, while another lays the tables. There is a domestic type washing machine and tumble dryer available, and individuals are encouraged to do their own washing, although a central laundry is available for those who either can’t or choose not to. People are also encouraged to clean their own rooms, with staff support as appropriate. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 15 The Hollies provides a cooked meal for lunch and tea, with people encouraged in making their own decisions and choices for breakfast. Drinks and snacks are available through the day. Discussions with people at the home, showed that they were happy with the quality and quantity of food on offer, with comments such as: “It’s nice”, “very good, and we get plenty to eat”, the food is fine, very good, lots of choice, and we get plenty to eat.” There was clear evidence that staff had been trained in food hygiene, and safe handling of food, with certificates on display on the kitchen wall. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 & 20 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People have their health care well managed, and are supported in a positive manner by the staff. Medication is well managed at The Hollies, which means that people living at the home are safe, and are having their healthcare needs met by the staff. EVIDENCE: Discussions with three people, who live at the home, showed that people were able to make choices, and felt in control over their personal care. This extended through whether to have a shower or a bath, and which member of staff (if any) would assist them. Currently there are only female staff in post, so choice in relation to the gender of staff offering personal care is limited. This was discussed with the manager, who said that she would like to recruit some male care staff, but there had been problems in finding suitable male applicants. Personal care choices were outlined within care plans. The four files that were seen all had a section relating to physical health, and included details of visits to the doctor, hospital, or nurse. Discussions with The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 17 people who live at the home showed that they are registered at the local surgery, and go to see the doctor if and when they need to. In their AQAA they said: “We involve the clients in decisions with regard to their personal care, in choosing their preferred General Practitioner, and we support the client to gain access to all primary health care facilities. We observe our clients, discretely, and we offer help and support to adapt their care delivery specific to changes in mood and presentation, and their physical condition.” Boots the chemist provides The Hollies with their medication. An inspection of The Hollies’ medication systems showed that medication is handled safely. Administration records were seen and found to be complete. Two people currently living at The Hollies self-medicate, care plans and risk assessments were seen, and storage and monitoring systems were safe and working to protect the individuals concerned. All aspects of the medication procedures that were seen showed a clear audit trail for medication, and indicated that people living at the care home were safe. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People are safe, and feel their views are listened to and acted upon. EVIDENCE: The Hollies has received five complaints (identified in their AQAA) since the last key inspection in August 2006. However the Commission have not received any complaints or concerns about this care home in that time. A review of the complaints showed that they had been dealt with in line with the home’s complaints procedure, which is on display in the foyer, and also forms part of the service user guide. Discussions with three people who live at the home indicated that they knew who to complain to, and how to complain, although they all said they had never needed to. In their AQAA The Hollies said: “We promote a culture that is important to capture the concerns, complaints and suggestions of all who support our service, clients, families and staff members alike. A review of the staff training records in relation to safeguarding adults, and a review of the statistics showed that sixteen out of seventeen care staff had undertaken this training. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering people greater protection against abusive practice, while also making sure that the staff understand the correct policy and procedure to follow if abusive practice is found. Five members of staff were asked about safeguarding adults training and they said they were aware of the issues, and had undertaken this The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 19 training. The training offered has been a mixture of in-house training and courses run by external agencies such as Derbyshire County Council. The Hollies have not had made any safeguarding adults referrals since the last key inspection. The manager said that a copy of the ‘No Secrets supporting guidance for staff working with vulnerable adults’ has been given to every member of staff, and a further copy was seen displayed on the staff notice board. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. The Hollies provides a clean, safe, homely and comfortable environment, with good quality fixtures and fittings. This means that people living at the care home have a well equipped home, which meets their varied needs. EVIDENCE: The Hollies is a very comfortable and well appointed care home. Most of the bedrooms are in a bed-sit format, with each person having two rooms, a bedroom and a sitting room, with en-suite facilities. There are also two self contained flats, which are available for people who are moving towards greater independence. The communal areas are spacious and well appointed, with numerous sitting areas, and a games room with a pool table, and table top games. The entire building is on one level, and there are hand rails for those with restricted mobility, as well as walk in showers, and adapted baths to help those people who might find it difficult to use an ordinary bath. There is a central courtyard with sitting areas, and a paved area to the front of the The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 21 property wit additional seating and hanging baskets of plants and flowers. Discussions with several people about their bedrooms, and the accommodation in general, led to invites to view several bedrooms, where it was very obvious that people were more than happy with the accommodation on offer. In their AQAA they said: “Although our care home is designed to provide for a number of clients, we provide accommodation to give as much individual choice as possible. Clients are encouraged to take ownership of their own accommodation.” Discussions with staff members showed that there were systems in place for cleaning, and that The Hollies had a good supply of cleaning materials. The building was found to be clean, and smelt fresh, with obvious signs of a systematic cleaning regime in place. In relation to cleaning they said in their AQAA: “We strive to provide a clean, fresh smelling and comfortable environment, we operate policies to promote infection control.” The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. There is a competent, well-trained and supervised staff team that has been professionally recruited to support people at The Hollies, and meet their needs. EVIDENCE: The staffing rota for The Hollies was reviewed and this showed that there was enough staff currently employed to meet people’s needs. The rota identified that the staff team has a structure and a hierarchy, with senior staff on duty on each shift to offer leadership and direction. The files of four members of staff were seen, to check that they contained all of the information that would show that staff at The Hollies had been recruited in a safe manner – namely that applicants had filled out an application form, provided two written references and had had a Criminal Records Bureau check. The documentation showed that The Hollies’ recruitment policy and procedure had worked to protect the people living there. Discussions with five members of staff about their recruitment showed that they had gone through all of the pre-employment checks, and had not started working until those The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 23 checks had been completed. In their AQAA they said: “We have robust recruitment and induction procedures. We give great emphasis to interviewing our staff to seek out their past experiences, through references, CRB and POVA checks.” A review of the staff training records showed a staff team that had received a sound basic training, and that was receiving regular updates to enable them to do their jobs, this includes the mandatory training courses such as fire, food hygiene and moving and handling for example. Discussions with five members of staff about training showed that they all thought they were well trained, and that additional training was available on request, if it was identified as being needed. The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the staff training records showed that currently there are seventeen care staff at the home, of whom there are eight staff with NVQ level II, and six more currently undertaking their NVQ II. In addition there are two people with NVQ level III qualifications, and one more studying for their level III. The Hollies has a formal staff supervision system in place, in which staff receive supervision, either with the manager or with one of the other senior members of staff. This is usually in a one to one meeting. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. Five members of staff were asked about formal supervision, and they all said they felt well supported, and were receiving regular supervision sessions. Staff records of formal supervision were seen, and these showed that the National Minimum Standard recommendation of six times a year is being met. In their AQAA they said: “We supervise and appraise our staff, adopting the principal of life long learning, and through providing both in-house and external distance learning courses, we can continually increase the knowledge base and skills of our staff.” The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 & 42 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. The Hollies is a safe, well managed, and organised care home, with good recruitment and quality assurance systems in place to ensure that the people who live at the care home, are having their health and social care needs met. EVIDENCE: Mikayla Pawley is the Registered Manager. She is suitably qualified and experienced, and she has been judged by the Commission for Social Care Inspection to be a fit person to run a care home. Mikayla became the registered manager in July 2007. Observation of the organisation and running of the care home during the inspection visit, and discussions with staff members showed, a staff team that was well motivated, and knowledgeable about their roles and responsibilities. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 25 The Hollies have a survey/questionnaire for the people who live at the home, with the last one having been given out in July 2008. The main response to these questionnaires was that people thought the building needed redecorating. Over the last few months several areas have been redecorated, with people asked for their thoughts and suggestions on colours, both individually and in meetings held for the people who live there. Copies of the minutes of these minutes were seen, and they demonstrated that there is good consultation between the staff and the people living at The Hollies, with people encouraged to raise issues and ask questions of the staff. In their AQAA they said: “We attach great importance to gaining our clients views, and taking them into account and ensuring that our clients are fully informed and aware of the purpose of our actions. We recognise that some may require advice and support from their families, from advocates or by promoting information in different ways, in different formats or languages, but above all we ensure that our clients have an opportunity to make their views known such that we can demonstrate their input is heard and acted upon, and that we can review outcomes.” Copies of Regulation 26 visit reports were seen, these are monthly visits by the proprietor or their representative to check on the management and running of the home, and ensure that the quality of care is up to standard. Discussions with a number of people who live at the Hollies and observation of activities and staff interactions during the inspection visit demonstrated that staff are proactive in ensuring that people have an enabling lifestyle, and that people who live at the home are able to voice their opinions, and have these noted and acted upon. A good example being the redecoration which followed from the questionnaires, identified above. A range of different health & safety records were seen, including the fire safety records, water temperature checks and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up-to-date, which shows that people are living and working in a safe environment. Discussions with staff members showed that people had received relevant training in Health & Safety, and this was supported by the staff training records that were seen. The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 26 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 4 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 4 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 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 4 13 4 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 4 X X 3 X The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 27 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. Refer to Standard Good Practice Recommendations The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 The Hollies DS0000020018.V373420.R01.S.doc Version 5.2 Page 29 - 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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