Care Home: The Hollies Care Home

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What the care home does well The Hollies provides a warm, friendly and caring environment for people to live. People who live there spoke of being happy and were very positive about the staff who provided their care. They are able to make choices and decisions about their daily lives. People said, "I make my own decisions and live my day to day life as I choose". "It is a friendly environment and the staff are very supportive". "I meet with my keyworker, she is there if I need to talk to her and I am aware of my care plan". Staff are well trained and 67% are trained to NVQ 2 or above. People who live at the home said, ""We are all different, and receive support in different ways, they know our needs". People who work at the home are very positive about their job roles. They said, "I really enjoy working here, the atmosphere is brilliant, residents are fabulous and it is a nice place to come to work". People thought the home was well run. They said, "It is a well run home, you have a voice and if you have anything to say you can easily say it". "It is very good here, I am quite settled, there is nice staff, Julie and Jackie are really approachable, I can talk to them". What has improved since the last inspection? This is the first time The Hollies has been inspected since the change of ownership. Substantial improvements have however been made including improvement to the assessments and care records, the environment and the way in which medication is managed. What the care home could do better: It is commendable that so few areas have been identified as in need of improvement. Some of the risk assessments need further information. Further development to activities would improve opportunities for social, educational and recreation for people who live at The Hollies. Further advice is needed in respect of the management of medication when people go home on leave. Some additional environmental improvements are needed; these include those already identified by the home but also the replacement of one of the lounge carpets, replacement of flooring to bathrooms, the seal to the visitors toilet and the cleaning of the ventilation fans. CARE HOME ADULTS 18-65 The Hollies Care Home 447 Norton Road Norton Stockton-on-Tees TS20 2QQ Lead Inspector Jackie Herring Key Unannounced Inspection 13th May 2008 9:30 The Hollies Care Home DS0000071204.V364246.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 Care Home DS0000071204.V364246.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 Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Care Home Address 447 Norton Road Norton Stockton-on-Tees TS20 2QQ 01642 550407 F/P 01642 55407 the.hollies@ntlbusiness.com 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) Vorg Hollies Ltd Julie Marie Gregory Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places The Hollies Care Home DS0000071204.V364246.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 service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Mental Disorder, excluding learning disability or dementia, Code MD maximum number of places: 18 The maximum number of service users who can be accommodated is: 18 This is the first inspection since change of ownership. 2. Date of last inspection Brief Description of the Service: The Hollies is a large detached house built in 1801, similar in style to others in the area and does not attract undue attention. The home is registered to provide 18 beds for adults with mental health problems. There are twelve single rooms and three double rooms. None of the rooms have en-suite facilities. The home is close to the centre of Norton. It has secluded gardens to front and rear with car parking spaces for visitors. Shops, churches, library, community and medical services are close by. There is a bus service to Stockton and Middlesbrough. The current fees are £363.88 per week. The Hollies Care Home DS0000071204.V364246.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 stars. This means the people who use this service experience good quality outcomes. This is the first time The Hollies has been inspected since owned by Vorg Hollies Limited following a change of ownership and was registered on 23 November 2007. The first day of inspection was unannounced. The second day was planned so that the proprietor was present for feedback. One inspector conducted this inspection in seven hours. This Key Unannounced Inspection was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in two-inspection day, seven inspection hours by one inspector. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. A number of surveys from people who live at the home and one from a relative were also received. Time was spent talking to people who use the service, relatives and staff. Time was also spent walking around the home, observing interactions and generally finding out what The Hollies was like for the people who live there and staff. Discussion also took place with the manager and proprietor. This was a very positive inspection and much commitment to continuous improvement was demonstrated. The manager has completed the Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards. This was received prior to the inspection and some of information has been reflected within the report to support the judgements made. What the service does well: The Hollies provides a warm, friendly and caring environment for people to live. People who live there spoke of being happy and were very positive about the staff who provided their care. They are able to make choices and decisions about their daily lives. People said, “I make my own decisions and live my day to day life as I choose”. “It is a friendly environment and the staff are very supportive”. “I meet with my keyworker, she is there if I need to talk to her and I am aware of my care plan”. The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 6 Staff are well trained and 67 are trained to NVQ 2 or above. People who live at the home said, ““We are all different, and receive support in different ways, they know our needs”. People who work at the home are very positive about their job roles. They said, “I really enjoy working here, the atmosphere is brilliant, residents are fabulous and it is a nice place to come to work”. People thought the home was well run. They said, “It is a well run home, you have a voice and if you have anything to say you can easily say it”. “It is very good here, I am quite settled, there is nice staff, Julie and Jackie are really approachable, I can talk to them”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Hollies Care Home DS0000071204.V364246.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 The Hollies Care Home DS0000071204.V364246.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): Standards: 3 & 6 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People have their needs assessed before being admitted to the home and they were assured those needs would be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The statement of purpose was looked at and in the main contained the appropriate information. Some slight updating was needed regarding the address for CSCI and some additional information regarding complaints. The manager was underway with this during the inspection. The AQAA detailed the way in which people are admitted to The Hollies. It states, “All potential service users are able to visit, share meals, and have over night stays. We receive a comprehensive risk assessment, joint assessment tool documentation and a copy of an up to date CPA (Care Programme Approach) document to ensure we are able to meet the needs of the service user. All new service users have a comprehensive needs assessment; these needs assessments include service users aspirations and needs”. People who live at the home and staff have involvement in the possible admission of new people to the home. One person said, “Everyone if involved in new admissions, we all have an input”. The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 9 Two sets of records of people living at The Hollies was looked at, one of which was someone who had lived at the home a short time and another for someone who had some complex needs. In both records looked at there was pre admission information along with care management information. Discussion with one of the people living at the home confirmed there had been opportunities to visit prior to moving into The Hollies. The Hollies Care Home DS0000071204.V364246.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): Standards 6, 7 and 9 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People receiving the service are happy with the way in which care is delivered by staff and are able to make choices. Records detailing how personal care is to be delivered are detailed and clearly identify individual needs. Some additional information would enhance the risk assessments further. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The same two sets of records were looked at in more detail. There was very good person centred information in place along with a good history and clear assessments of needs. The records had a good order and flow to them. Staff who were spoken to say that the care records were much improved and were much better to understand and use. People who live at the home confirmed that they were aware of their care records and that they had been consulted and were involved in the information contained within them. They also confirmed that they met with their keyworker to discuss their needs and progress made. One person said, “I meet with my keyworker, she is there if I The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 11 need to talk to her and I am aware of my care plan”. “We are all different, and receive support in different ways, they know our needs”. The care records gave good information about the individual person and their needs. Specific care plans were well written. A range of risk assessments were in place where needed. Some of the risk assessments needed some additional detail for example for the risks associated with smoking in bedrooms. It was also good to see additional information in place such as, “What is schizophrenia” and diabetic information, which increases support workers knowledge. Care records had been signed by the person who uses the service. The AQAA detailed, “All staff carry out weekly key work sessions with the service users to ensure they receive the full support to promote their independence”. It was good to see people who live at The Hollies freely accessing their kitchen and making hot drinks. Another person was doing their personal ironing and other people were observed to be freely going out or spending time as they chose. One person said, “I make my own decisions and live my day to day life as I choose”. Another person said, “I can have a lie in and I go out with my family and can go out around the village when I want to”. The Hollies Care Home DS0000071204.V364246.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): Standards 12, 13, 15, 16 and 17 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People are treated with respect. Whilst activities are available, further development will lead to more opportunities for social, recreation and occupational interests. People benefit from maintaining where possible personal relationships and have their right respected. Meals are provided to a high standard within a suitable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of people who live at The Hollies were spoken to during the inspection and observation took place across the two days the home were visited. People said, “It is a friendly environment and the staff are very supportive”. The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 13 The manager and deputy manager said that they were looking to develop and improve opportunities for people to be involved in more social, occupational and educational activities. A range of workshops had been offered including confidence building and assertiveness, however to date no one has wanted to attend. Staff thought that motivation continues to be the main challenge in developing and implementing this. One of the support workers is trying to develop some additional activities and this is discussed regularly at the meetings held in the home with the people who live at The Hollies. One of the people who live at The Hollies thought that the range of activities could be improved and be more constructive. One person talked enthusiastically about their job working in a local charity shop and the help they gave within a local community centre. They also said that they had enjoyed doing some open learning courses including, Equality and diversity, food and hygiene, nutrition and health and infection control. Another person had also completed one of the open learning courses and was being supported by staff to complete a second course. It was clear that people were free to make decision about their daily lives and that there was support for those people who needed this. Where bedrooms are being shared a signed agreement is completed. This was observed to be in place in one of the files looked at. One person said, “I wash up, set the tables, go to the shops and I like to read a lot. Life if very flexible”. A member of staff said, “I believe people enjoy their lives here, activities are available, it is relaxed and people are able to make decisions and have choices”. People are able to maintain links with their family and friends. One person had recently been to stay with their family and another person was going to a family christening. A phone is available for use by the people who live at the home. People spoke very highly of the meals provided at The Hollies. They said, “The meals are very good, there is a lot of variation and choice and they have also introduced a more health option”. Another person said, “The meals are much improved particularly the vegetarian option”. The daily menu was on display on a chalkboard within the dining room. There were two choices each mealtime as well as a vegetarian option. Staff had completed a course on nutrition, as had one of the people who live at the home. The Hollies Care Home DS0000071204.V364246.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): Standards 18, 19 and 20 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who use the service have their healthcare and personal care needs are met by staff who provide support in a sensitive and flexible manner. Medication systems and records are good and only staff who have received the appropriate training have any involvement with medication. EVIDENCE: The AQAA states, “The staff provide support to promote independence and maintain service users privacy and dignity”. People who live at The Hollies said that they could make their own decisions about their daily lives and there was appropriate support in place when needed. The records looked at detailed involvement of GP, Consultant Psychiatrists, Care Programme Approach reviews and all health related matters. Staff said the home works closely with external professionals and specialists for advice and support to help the service user and the home’s staff. People who live at the home confirmed that both their physical and mental health needs were well met within the home. Staff also said that as well as meeting people’s psychiatric health needs they also had the medical needs met. In one of the files looked at, it was unclear who was monitoring one person’s diabetic care. The manager responded to this straight away. Another person who lives at the home was being supported through a physical health problem. The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 15 The way in which medication is managed within the home was discussed in detail with the deputy manager. Good systems were described from the ordering of medication and appropriate storage. Only staff who have completed the required training are involved in the administration of medication and only after on-site assessments have been conducted and the deputy manager or manager are satisfied with the standard and knowledge attained. Additional information was in place such as a learning file containing a range of information relating to medication in use within the home, which was good. The medication administration records are also supported by additional information about “as and when required medication” and “variable doses”. This information gives guidance on when to use this medication, the circumstances and possible triggers”. Storage was appropriate and records were well written and completed. Audit of the full medication systems was seen. It is clear that a lot of work is being done in the area of medication management. One area that needs to be looked at is in relation to how medication is managed when people go home on leave. Further guidance and advice is being sought. The Hollies Care Home DS0000071204.V364246.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): Standards: 22 & 23 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who live at the home are confident their complaints would be listened to, taken seriously and acted upon, although the full procedure needed to made available. People who live at the home are protected from abuse by the home’s policies and procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA details that there has been one complaint within the last 12 months. This has been investigated and was not upheld. The complaints procedure was on display in the entrance of the home. This was a summarised version of the procedure and detailed most of the contact information needed; a little more information was needed regarding the proprietor. It was also agreed that a full copy of the procedure should be available to people without them having to ask for it. The manager is going to included the fuller version within the statement of purpose, which is available on the sideboard within the dining room. One person who were spoken to said if they had concerns they would, “Go to the boss, Julie and I have never felt the need to go beyond Julie”. Another person said, “I would speak to my keyworker and if I continued to be concerned I would go to Jackie (Deputy Manager) or Julie (Manager). All staff have recently completed an E-Learning programme on Safeguarding. A copy of the No Secrets protocol is available within the home and staff spoken to were fully aware of this and the action to be taken, should this be needed. The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 17 There have been one safeguarding issues, which has been dealt with appropriately. The Hollies Care Home DS0000071204.V364246.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): Standards: 24 and 30 were looked at during this inspection. People who use the service experience good quality outcomes in this area. The home provides an environment that is appropriate to the specific needs of the people who live there. People are able to personalise their bedrooms and the home is warm, clean and comfortable. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Hollies is a converted property and provides 12 single rooms and 3 double rooms. None of the bedrooms have ensuite facilities however there are a number of bathrooms situated in suitable locations in the home. The AQAA detailed a number of environmental improvements, which were confirmed by the manager during the inspection. They said that a large number of improvements have been made to the environment including redecoration to a number of areas, the purchase of new pictures and a new The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 19 lounge suite. A number of carpets had been replaces and the fireplace in the dining room had been opened up and a tropical fish tank had also been purchased. They also said that a number of other improvements were needed some of which were detailed in the AQAA and they had a plan in place for this. The carpet in the large TV lounge could do with being replaced as does flooring to bathrooms, the seal around the ground floor toilet needs attention, as did the extractor fans. During the inspection feedback, the proprietor instructed the manager to obtain a quote for the carpet and for the other areas to be addressed. A member of staff said, “Money has been spent on the home, the environment is much better and it is more homely for the people who live here”. The home was fresh and clean on both inspection days. The housekeepers was spoken to who confirmed that they were responsible for the main areas of the home such as bathrooms, lounges etc and that the support staff then assisted the people who lived at the home to clean their own rooms. There was a smell of cigarette smoke from the smoking room that is used by the people who live at the home. The manager said that advice had been taken from fire and environmental health and the ventilation was deemed as appropriate. There was discussion with a person who shares a double room. There are currently no privacy screens in place, however the person said they had no concerns about this. One person spoken to has a computer in their room with access to the Internet, this was very important to them. Other people said they were very happy with their rooms; they spoke of having their personal belongings such as TV’s, DVD’s and their books. An area that has been identified as in need of improvement is the garden. The AQAA details that plans are underway for this and staff also said that work has commenced and that they are also planning a vegetable patch. The Hollies Care Home DS0000071204.V364246.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 & 35 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who live at the home have their needs were met by the numbers and skill mix of staff who were trained and competent to care for people who live at the home. People are protected by the home’s recruitment procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff spoken to believed there were sufficient staff on duty to meet the needs of the people living at The Hollies. People who live at The Hollies also thought this. Three staff files were looked at and they contained all of the information needed to show good recruitment procedures. This included a completed application form with good employment history, references and Criminal Records Bureau checks. This was also confirmed with three staff during discussions. The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 21 People spoke very highly of the staff, they said, “The staff are very friendly and relaxed and you can speak with them”. Another person said, “The staff are nice, they care and are helpful”. A further person said, “The staff are all friendly, they deserve respect, they are doing a good job at the end of the day”. One member of staff said, “We have a solid staff team and we are constantly training, it is a good staff team who are reliable”. The training records, along with matrix and training plan were looked at. It detailed both mandatory training and more service specific training such as, mental health. A training plan was in place dated April 2008 – October 2008. Individual training files were looked at and this contained copies of training certificates. Approximately 67 of staff are qualified to at least NVQ Level 2 in care and the remainder of the staff are near completion. It was also confirmed through discussion with the manager and deputy that Skills for Care induction is in place and that they adapt it for other staff such as the housekeeping and maintenance staff. The Hollies Care Home DS0000071204.V364246.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 & 42 were looked at during this inspection. People who use the service experience good quality outcomes in this area. The home is well managed and run in the best interests of the people who use the service. The health, safety and welfare of people who live at the home and staff was promoted and protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: An appropriate experienced and knowledgeable person who has the required qualification and who is registered with CSCI manages the home. One of the people who live at the home said, “There have been a number of changes, all for the better”. Another person said, “It is very good here, I am quite settled, there is nice staff, Julie and Jackie are really approachable, I can talk to them”. One member of staff said, “I am very positive about the home The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 23 and the progress made”. The AQAA detailed in ‘what could be better’, “We are striving for continuous improvement in training, staff development, maintaining the environment and service user involvement. We are striving to promote an independent lifestyle for all our service users”. Other staff who were spoken to said, “I love it here, it’s a nice atmosphere, you can express yourself and have an opinion”. Another member of staff said, “It is a well run home, you have a voice and if you have anything to say you can easily say it”. “I really enjoy working here, the atmosphere is brilliant, residents are fabulous and it is a nice place to come to work”. Quality assurance systems were discussed with the manger who said that they were not completely satisfied with the customer satisfaction component and was looking to develop and improve this further. Currently questionnaires are sent to relevant people and a short summary is produced. Other systems include a range of audits of the systems in place within The Hollies such as care plan audits and medication audits. A sample of maintenance records were looked at such as Gas Landlord certificate and Fire Alarm servicing, which were in order, others were fully detailed within the AQAA. The Hollies Care Home DS0000071204.V364246.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 2 2 X 3 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 X 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 The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 25 N/A 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 YA24 Regulation 13 Requirement The extractor fans must be cleaned and serviced ensuring they are maintained. This will provide additional safety to the environment and for the people who live and work at the home. Timescale for action 01/07/08 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. 1. 2. 3. Refer to Standard YA1 YA9 YA12 YA20 Good Practice Recommendations The statement of purpose should be updated and include up to date contact details for CSCI and the full procedure for complaints. Some of the risk assessments need to have additional information to demonstrate the seriousness of the risk and the actions to be taken. More opportunities should be developed for people to be involved in other activities that will enhance their lifestyle. Further professional advice is being sought in regard to management of medication for people going on leave to make it more robust. The policy and procedure should then be updated if this is appropriate. Consideration should be given to replacing the carpet in DS0000071204.V364246.R01.S.doc Version 5.2 Page 26 4. YA24 The Hollies Care Home the large TV lounge and flooring to bathrooms. The seal around the visitors’ toilet should be replaced. The Hollies Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Care Home DS0000071204.V364246.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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