Inspection on 10/12/07 for Holicote

This inspection was carried out on 10th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holicote 24/11/06

Holicote 18/01/06

Holicote 09/02/05

Holicote 20/07/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Holicote 93 Newton Lane Darlington Durham DL3 9HH Lead Inspector Carole McKay Key Unannounced Inspection 10 and 17th December 2007 2pm th Holicote DS0000038029.V354529.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 Holicote DS0000038029.V354529.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. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holicote Address 93 Newton Lane Darlington Durham DL3 9HH 01325 469707 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) Darlington Borough Council Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2006 Brief Description of the Service: Holicote is a care home providing personal care and accommodation on a short-break basis for up to five adults (aged 18 - 65) with learning disabilities. It is a local authority home (Darlington Borough Council), which operates as part of local (joint health and social services) learning disability services. Holicote is a purpose built bungalow, situated in the Cockerton area of Darlington. There is convenient access to public transport nearby. Service users stay in single bedrooms. 2 bedrooms are suitable for people who also have physical impairments. Suitably equipped bathrooms / toilets are provided. Stays at Holicote are for agreed periods to provide respite care for both the service user and their carers at home. Service users can also stay at Holicote for shorter periods, during the day or evening, or for a meal. Fees charged by the home are £315 per week. If people stay for just a teatime meal they pay £1 for this. The home has a copy of the service user guide, statement of purpose and copies of recent inspection reports, are available. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 6/12/07 • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives and staff. The Visit: An unannounced visit was made on 10th and 17th of December 2007. During the visits we: • • • • • • Talked with people who use the service, a relative, staff, the manager & a visitor. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit . We told the manager what we found. The visits took place over 8 hours, on the afternoon of Monday 10th December and the afternoon and evening of Monday 17th December 2007. In line with current CSCI policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. Four surveys were returned. All of these were from staff. Within the limits of their communication and understanding, service users were also spoken to. On the second day an evening meal was taken with the staff on duty and the people using the service. What the service does well: Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 6 Holicote provides a good standard of respite care to the people who stay there. 56 people and their families are currently receiving support from the service. Holicote is furnished and equipped to a high standard. It is homely and meets the needs of people who stay there. In surveys the staff offered the following opinions; “The service given here at Holicote works very well, we have a good open communicative team, with a variety of experience, who I feel give a high standard of care and support to the individuals who access the building and their parents, carers.” “Give service users independence learn new skill, short break to meet old and new friends ,give parents carers freedom and a break.” “ put staff forward for NVQ to enhance knowledge, gives good care to all service users.” “ I feel the staff team do very well meeting the needs of the service users. It has been hard with all the changes of managers.” What has improved since the last inspection? The home has introduced surveys. These have been sent out to service users and their representatives so that their views are taken into account when developing the service. The home now has stable management arrangements. A full time permanent manager has been appointed. This means that service users can rely on a consistent service. The home has had agreement that an extra fifty-six staff hours per week will be provided on a permanent basis. Recruitment is underway. Service users will be able to enjoy a higher level of individual support. Forum meetings have been introduced where people who have an interest in the service are consulted. Individual risk assessments and risk management plans have been introduced so that support is provided in the way that is best for each individual using the service. Menus have been reviewed so that people who use the service can make wider choices. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 7 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. Holicote DS0000038029.V354529.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 Holicote DS0000038029.V354529.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ introductions and admissions to the home are properly managed. EVIDENCE: A Statement of Purpose, a Service User Guide and other information leaflets in pictorial formats are available to service users and their families. Upon admission a terms and conditions agreement, which is also in a pictorial format, is written out. Holicote provides short-term care only, for adults (aged 18 – 65) with learning disabilities. People who have physical impairments can also stay at the home. These short-break stays are usually pre arranged and for an agreed duration. They can be overnight stays or for a shorter length of time, for example to stay for a meal. The manager said that wherever possible people who are new to the service are introduced gradually. This means that they can get to know the staff and r some of the other people who use the service, before they stay overnight. These introductory visits usually involve having tea in the afternoon, staying Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 10 for the evening, or one overnight stay. The introductory visits are part of the process of assessing the needs of the person. People can use Holicote after a team of people employed by the local borough council learning disability service has carried out an assessment of their need. This also determines the amount of access a person will receive, depending on their needs. There is some evidence that this process can be frustrating at times for the staff team. The following comments were received in staff surveys: “Occasionally it has taken quite a long time to receive relevant information from parents/carers and care co-ordinators, to accommodate peoples stays.” “ It does take some time for us to receive the information from parents carers and co-ordinators.” “ Care co-ordinators do not always give us up to date information.” “ sometimes it takes us a while to get a sezure map (sic) and other information on the service users” The manager said that the booking of stays would, in future, be carried out by the local team, rather than by staff at the home. Some of the staff voiced concerns about how well this will work. And the visitor voiced some doubts about this also. This is because the staff team at the home are worried that they and the service users lose control of the pace of the introductory visits and their ability to match visits to individual service users preferences. But staff also recognise the need for fairness in the booking system, as described in earlier sections of the report. Also the manager said that the Council has plans to have in place a process whereby staff at the home can access information about the needs of service users at a central point using information technology. This should overcome the delays in obtaining information. The assessments examined are very thorough and a good standard of information is provided to the service before people come to visit for the first time. The home also has processes for updating their knowledge of each person in between stays at Holicote. Holicote DS0000038029.V354529.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. For the duration of their stay, service users’ needs and choices are met by the home. Wherever possible people are supported to make decisions and achieve aspirations. EVIDENCE: An information gathering questionnaire, ‘information about yourself’, is given to each new service user and their carer for completion prior to admission, which lists likes, dislikes and lifestyle preferences. As staff get to know individual service users, the service user plan of care is developed for each person. This ensures that individual needs and aspirations are met. Additional assessment information, through links with care coordinators and other professionals, informs ongoing care planning in the home. Changes to care plans are made as necessary. Decisions about lifestyle choices generally fall outside the direct responsibility of the home. However, when people come to stay at Holicote they are Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 12 supported to follow their existing social, recreational, educational or employment arrangements. Any decisions about risk are also considered during the assessment process in with the care co-ordination arrangements. At the last inspection a requirement was made about carrying out specific risk assessments for individuals. These are now being produced and the files examined included these. Risk management plans are in place now for the more dependent people who use the service. And all of the files have been audited to make sure that each service user has an up to date risk assessment and management plan. The new manager said that she was working through these, where updates were needed. Holicote DS0000038029.V354529.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Wherever possible, people are offered choice and any decision-making is appropriately supported. Care plans record service users’ needs and aspirations, together with the actions required and being taken to meet / achieve them. EVIDENCE: Any activities arranged fit with service users’ usual routines and lifestyles. On the days of the inspection a number of service users had been to day care placements. Over the evening meal the staff talked to the people using the service about how their day had been, and about plans for the next day. The service employs people who have learning disabilities. One employee was on duty during the inspection. She said that she had worked at the service for Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 14 a long time and that she enjoyed it. She was able to get a bus to work and the bus stopped right outside the home. The home has a minibus, though more use could be made of this if more staff were qualified to use it. The service exists to provide short-term breaks to ensure family support can continue. When people stay at Holicote, wherever possible family and other relationships are supported. The relative who was spoken to said that she felt fully involved and consulted about the care her relative received. Since the last inspection and in response to recommendations made the menus are being revised to take account of the seasonal changes and preferences of the people who come to stay at the service. The menus themselves are being presented in a way that supports people to make choices, by using photographs and pictures from magazines. The meal taken as part of the inspection was warm, nicely cooked and presented. The staff offered choices to the people staying at the home, about what they ate and how they ate it. Some of the people at the home at the time of the inspection needed significant support with eating. The staff managed this very well. Support was given in a dignified manner and in a way that was very sensitive to the needs, feelings and wishes of each person. The meal was unhurried, relaxed and an enjoyable social occasion for all participating. Holicote DS0000038029.V354529.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and health care needs are met. Some updates to staff training are needed to make sure that staff can continue to safely support service users with managing their medicines. EVIDENCE: Service users are encouraged to follow their normal daily activities whilst staying at the home. Personal and health care needs are met for the duration of each person’s stay. Each file examined contained all the necessary information to do with emergency contacts and health care support. Individual risk assessments to do with health needs are being updated by the new manager where necessary. The files examined included suitable health care management plans. Where special techniques are being carried out staff have been trained in these. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 16 Other health professionals have been consulted and involved in the assessment and care planning process also, as necessary. For example physiotherapists and speech and language therapists have contributed for some of the people who use the service. Copies of reports and assessments by specialists are available to staff in the care files. The home has appropriate policies and procedures about the receipt, recording, storage, handling, administration and disposal of medication. Whilst none of the service users who were staying at Holicote manage their own medication, service users’ / carers’ consent is obtained for the home to handle such arrangements and this is recorded in individual care plan. On 18th June 2007 the Darlington Primary Care Trust Pharmacy Team audited the medication arrangements, by invitation. A report was sent to the home following this visit. Some recommendations were made in the report. These have been addressed. Staff have received training in medication by Darlington Borough Council. For some of the staff this was several years ago, and they have not had updated training since that time. Holicote DS0000038029.V354529.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to respond to any complaints. Service users are safeguarded from abuse. EVIDENCE: As part of the local authority structure, Holicote has adopted the council’s ‘Compliments, Concerns and Complaints Procedure’. This procedure is clear and effective and includes timescales and access to senior managers of the organisation. An easy to read summary of the procedure is included in the service users guide. Service users and their relatives are able to share concerns / complaints with staff members and are provided with information regarding advocacy. The home also has a ‘suggestions box’. In discussions with the inspector a relative said, “Any problems I have are sorted out with staff face to face.” The home, through the local council, has detailed adult protection procedures. Copies of these were seen to be available for staff use. These procedures are clear, effective and include appropriate timescales. Updated contact and on-call information is available within the home. The Commission (CSCI) has received no concerns or complaints since the last inspection. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 18 Staff have received training specifically relating to adult protection to ensure that they are aware of the initial action to be taken (things to do and things not to do) if an allegation of abuse were to arise. The manager said that training in the local procedures that have to be followed if staff suspect abuse is mandatory. All staff received this training in 2007. Staff who responded to the survey questions about this answered “yes” to the question- “do you know what to do if a service user, relative, advocate or friend has concerns about the home?” Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 19 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. Holicote provides service users with a homely, safe, well-maintained environment. Carefully managed bookings and improved storage will ensure that this continues. EVIDENCE: Holicote is a five-bedroom bungalow, built in 1999 by Three Rivers Housing Association, with specifications overseen by Darlington Social Services Department. Property matters are now managed in a partnership between Three Rivers Housing Association and Darlington learning disability service. Holicote has a homely and comfortable environment. Facilities include: Five bedrooms for single occupancy, two with adjustable beds. Bedrooms, which are attractively furnished and have TV/Video recorders, secure facilities for storing valuables as well as a key to each room. The home was purpose-built with easy access for wheelchairs. Hoist and lifting aids including overhead tracking in the bathroom and 2 bedrooms. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 20 Access to the garden via a patio from the dining room. Lounge, separate dining area and kitchen. Separate bath, shower and toilet facilities, all with easy access. The building was clean, tidy and free from offensive odours. There is a separate suitably equipped laundry and a separate sluice room. Appropriate systems are in place to prevent the spread of infection. The home also has a small, but useful office, which has recently been rearranged and refitted to make better use of the space available. Holicote is safe, well-maintained and appropriately decorated. It was purpose built and appropriate environmental adaptations and disability equipment are provided to meet the needs of the service users who currently use the service. Any additional equipment is obtained if assessed needs dictate. Holicote is being used more and more by people who use wheelchairs. As a result, available space within the home, especially in the lounge and dining room can be limited. Staff said that it is very important that the booking arrangements take account of this, so that they can ensure the safety of service users. Additionally staff said that storage could be a problem. And on the day of the inspection several items of special equipment were being stored in the bedrooms, as there is no other separate designated storage for these when not in use. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff available supports the needs of the service users. The training for staff makes sure service users are safe and cared for. EVIDENCE: The home has eight permanent staff. In addition there are two nonpermanent staff that cover shifts as required. The staff team is very well established and there is a strong sense of teamwork. Some of the staff have worked at the home since it opened. Some of the staff said that they had seen how the needs of service users had increased in that time and that this has placed new challenges and pressures on the team. The staff have shared their views about this with the manager and other representatives of the Council. At the last inspection it was recommended that more permanent staff should be employed at the home, so that there be less reliance on bank staff. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 22 Recent experiences of the staff are reflected in the comments by staff in staff surveys. As follows; 1.” We have struggled with getting new staff members apparently due to ‘budget issues’, for over 3 years, however, this situation has slowly been rectified. Although the needs of most of our service users now are also increasing, faster than the staff are put in place.” 2. “we use alot of pool who do not know our clients ways and procedures and the way holicote is run making it harder for the permanent staff.” 3.” We always have enough staff on duty, however we still rely on staff good will to cover some shifts.” 4. “ I would like to point out that over the past ¾ years this service has been understaffed and over occupied, and yet the staff team have all remained consistent, hopeful and supported individuals, parents and carers, with little or no thanks, to the best of their ability now that this situation is gradually improving and a lot of the strain has been lifted, with the excellent staff team we have I feel this service will go form strength to strength.” (sic) The manager said that the staffing levels have been reviewed. There is an intention to increase these by 56 hours per week. Some of the hours that are currently being covered by temporary arrangements are to be made into permanent staff hours. As a local authority home, Holicote has adopted the council’s recruitment policies & procedures. These policies and procedures are robust and are based upon equal opportunities. The staff recruitment files are not held at the home and were not examined at this inspection. Other information to do with staff training and supervision is available. The new manager acknowledged that staff one to one meetings had fallen behind and she has re scheduled these to bring them up to date. All staff are to receive one to one meetings with the manager every six weeks. Each member of staff has an appraisal of their work once per year. Some of the completed records of these meetings were examined. They are well planned and recorded. Of the eight permanent staff, seven hold a national vocational qualification (NVQ) and one person is working toward this. Darlington Borough Council offers staff training. Some of the training on offer has to be taken by law and updated regularly. The manager demonstrated that she had arranged for these updates to take place in 2008. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 23 The staff on duty said that some specialised training is offered, but that there are areas, to do with service users’ needs, that are not covered and that they would like more training in. They are able to discuss this in one to one meetings with the manager. In surveys the staff responded, “yes” to all questions to do with whether on going training was relevant, up to date and helped them to understand and meet the needs of service users. In contrast, in response to questions about induction training, staff responded “not at all ” or “mostly” to the question- “did your induction cover everything you needed to know to do the job when you started?” There is no evidence that the training has been assessed for the impact it has on service users’ lives. This was discussed with the manager as a way to identify the relevance of staff requests for training and the training on offer through the Council’s rolling programme. Holicote DS0000038029.V354529.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has stable management arrangements and is being well managed, so that it develops by taking account of service users’ safety and opinions. EVIDENCE: Holicote is run by Darlington Borough Council’s (joint health and social services) learning disability service. The current manager has recently been appointed and is the second person to hold the post since the last inspection. The manager is not yet registered, though she has a lot of experience working at the service and is in full time day to day control of the home. This was a requirement made at the last inspection of the service. The manager has made application to be registered with CSCI and has completed the registered manager award in 2007. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 25 The senior manager of the service has carried out an audit of the service and has identified shortfalls that have occurred during the recent period of instability in the management arrangements. The new manager has an action plan for addressing these and has most of the work in hand. Since the last inspection, and as recommended, surveys for service users and their representatives have been introduced. These are user friendly and in easy to read format. In one of the surveys a service user said that having a male carer on the staff team would improve the service. Regular meetings take place with service user representatives at open forums and staff meetings are regularly arranged. These are recorded. A senior manager from the local authority visits Holicote regularly and monthly reports required under Regulation 26 of the Care Homes Regulations 2001 are completed and forwarded to CSCI. Darlington Borough Council have produced comprehensive policies and procedures to do with health and safety. Staff are instructed in these and carry out the necessary checks. Some of these policies have been translated into local procedures for staff to follow. Staff dealt with a false alarm on the fire safety sytem calmly and competently during the inspection. They called out the releven engineer to rectify the fault. Holicote DS0000038029.V354529.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 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 3 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 2 x 3 x 3 x x 3 x Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 27 no 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 YA20 Regulation 18(1) (c ) Requirement The manager must review the training needs of staff to do with medication. And ensure that staff have received the correct level of training for the support they are providing to service users and ensure that this is up to date. The manager must consult the CSCI professional website for guidance to do with Training Care Workers to Safely Administer Medicines in Care Homes. Timescale for action 31/03/08 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. Holicote Refer to Standard YA12 YA24 YA24 Good Practice Recommendations More staff should be trained to drive the minibus, so that more people who are unable to use public transport can get out and about more often. A designated storage area should be provided for special equipment that is not in use. The booking system should take account of the restricted DS0000038029.V354529.R01.S.doc Version 5.2 Page 28 4. YA35 5. YA39 YA2 communal space. The manager should carry out a training needs assessment for the staff team as a whole and an impact assessment of all staff development to identify the benefits for service users and to inform future planning. To ensure that staff are supported fully in meeting the needs of service users the quality assurance process should be used to monitor the efficiency of the assessment process. Staff should be consulted about this regularly. Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Holicote DS0000038029.V354529.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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