Inspection on 18/01/06 for Holicote

This inspection was carried out on 18th January 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holicote 10/12/07

Holicote 24/11/06

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 Mr Paul Emmerson Unannounced Inspection 18 January 2006 9:00 Holicote DS0000038029.V267647.R01.S.doc Version 5.0 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.V267647.R01.S.doc Version 5.0 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.V267647.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holicote Address 93 Newton Lane Darlington Durham DL3 9HH 01325 287831 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 Glenys Hillary Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: Holicote is a care home providing personal care and accommodation on a respite basis for up to five adults (aged 18 - 65) with learning disabilities. Holicote 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. The home provides short-break residential care. Service users are accommodated in single bedrooms, two of which 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 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. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. By law we have to inspect all care homes at least twice a year. This unannounced inspection was carried out in accordance with this obligation. The inspection took place over 3½ hours on the morning and afternoon of Wednesday 18 January 2006. In line with current CSCI policy on ‘Proportionality’, the inspection focused upon a number of key standard outcomes for service users. The key standard outcomes not inspected on this occasion were assessed during the last inspection of the home. The inspector looked around the building and a number of records were examined. The manager, 3 members of staff and 1 service user were spoken to. Within the limits of their communication and understanding other service users were also spoken to. What the service does well: What has improved since the last inspection? As required in the previous inspection report, additional permanent staff have been recruited, with others in the process of being appointed. As required in previous inspection reports, a registered manager has been appointed. Although this person is not in full-time day-today control of the home - because she has a more senior role within the learning disability service, which she is moving to on a permanent basis - her input into the home has been beneficial. As recommended in previous inspection reports, care plans have been reviewed. Some revised / updated documents are now being used, for example a pre-admission form ‘information about yourself’ has been reprinted in a simpler, easier to understand layout. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 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 Holicote DS0000038029.V267647.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. However, as highlighted in previous inspection reports, where service users remain in the home for longer periods, more detailed care plans should be developed. Care plans should identify individual needs, goals and aspirations; highlight the specific action / interventions required and being taken to meet such needs; and record ongoing monitoring and reviews. In such circumstances a key-worker should also be appointed. EVIDENCE: N/A Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. However, as highlighted in the previous inspection report, although it is acknowledged that within the homes care planning arrangements ‘general risk assessment’ documentation is being used, specific risk assessments for individual service users should also be developed in greater detail. EVIDENCE: N/A Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. However, as highlighted in the previous inspection report, records of food supplied should contain more detail. EVIDENCE: N/A Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Personal and healthcare needs are met. Any medicines required are dealt with correctly. EVIDENCE: Holicote stands as an integral part of services for people with learning disabilities. 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 the person’s stay. Where necessary, the home facilitates service users’ access to, and use of, community based health care services. Any medical needs, illness and changing needs over time, are considered within service users’ overall care management arrangements. From observations made and discussions with service users, management and staff, where personal support is required it is provided appropriately. Service users are provided with guidance and encouragement to ensure that their needs are met, thus promoting independence in a dignified and respectful manner. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 12 Care plans in the home are in the main sufficient to inform the delivery of care to individuals who stay there. It is acknowledged that much work has been done to bring care plans up to date. An updated information gathering questionnaire (‘information about yourself’) is given to each new service user and their carer for completion prior to admission. These contain questions relating to likes, dislikes and lifestyle preferences. However, although care plan documentation has been reviewed, as highlighted in previous inspection reports, all care plans require audit to ensure that they are up to date and identify goals, aims, objectives and progress. Where service users remain in the home for longer periods, more detailed care plans should be developed. Care plans should identify individual needs, goals and aspirations; highlight the specific action / interventions required and being taken to meet such needs; and record ongoing monitoring and reviews. Appropriate policies and procedures are in place with regard to the receipt, recording, storage, handling, administration and disposal of medication. Whilst none of the service users who are currently 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 plans. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. 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 Darlington Borough Council Social Services Department’s ‘Compliments, Concerns and Complaints Procedure’. This procedure is clear and effective and includes timescales and access to senior managers of the organisation. 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’. A pictorial version of the home’s complaints procedure has also been made available for service users. Information regarding the home’s complaints procedure and contacting the Commission is available within the home’s A-Z Service Users’ Guide. However, information within the Service Users’ Guide should be reviewed to develop protocols / guidelines regarding how complaints are processed and dealt with when they are received. The home, through the local authority 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. 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. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. EVIDENCE: N/A Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Appropriate staffing arrangements are in place. EVIDENCE: Due to the differing needs of the service users accommodated at any one time, staffing needs to be flexible. Some 82 service users are currently using the service at Holicote. Their needs, and the staffing input required as a consequence, are extremely varied. At the time of the inspection, staffing levels were found to be appropriate to meet the needs of the service users accommodated. It is acknowledged that the home’s staff complement has been reviewed. More full-time staff are now employed and recruitment is underway to increase staff numbers further. As part of the local authority, Holicote has adopted Darlington Borough Council Social Services Department’s recruitment policies & procedures. These policies and procedures are robust and are based upon equal opportunities. It is also noted that policies and procedures for Holicote are being reviewed to create more service specific documents for the home. Two written references are taken before employment can commence alongside relevant checks to ensure the suitability of potential staff. All new staff receive a statement of terms and conditions and all new appointments are subject to a probationary period. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 16 Although some updates are required, staff training and development is afforded high priority. All permanent staff have NVQ level 2 or above. However, as highlighted in previous inspection reports, it should be noted that at least 50 of all staff (including agency / pool staff) in the home should be trained to NVQ level 2. Although on the day of the inspection this percentage ratio was met, this Standard may require some further consideration in relation to the numbers of pool staff rostered. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Holicote is a well-run service, which supports service users and carers well. Appropriate quality assurance systems are in place to identify and rectify any concerns. EVIDENCE: Holicote is run by Darlington Borough Council’s Joint Learning Disability Service. Since the last inspection, as required in previous inspection reports, a registered manager has been appointed. This person has an NVQ level 3 (Promoting Independence) and in June 2005 completed the Registered Managers Award. She has considerable experience of working with people with learning disabilities. However, staffing structures and responsibilities within the local authority have recently been reviewed. As part of this review, the manager has taken up a more senior post as Community Inclusion Officer for Short-Term Breaks and Supported Living. Although the creation of this post requires the appointment of a new registered manager in full-time day-to-day control of Holicote, the existing post-holder is retaining responsibility until a replacement is appointed. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 18 Nevertheless a new manager is required. It must be noted that as highlighted in previous inspection reports, the registered manager must be in full-time day-to-day control of the home. Written assurance is required as to the intended future management arrangements for Holicote, which must be submitted together with a copy of any job descriptions for the role, setting out how this requirement is to be met. Service users’ and families’ views are obtained through regular contact and an ‘open door policy’. Coffee morning meetings are held, which provide an additional forum to discuss any concerns or potential difficulties. 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. The home through the local authority has a range of appropriate policies and procedures and systems are in place to ensure service users’ health and safety is protected. For example, health and safety checks are carried out. It is also noted that policies and procedures for Holicote are being reviewed to create more service specific documents for the home. Documents examined and discussion with the home’s management and staff during the course of the inspection confirmed that appropriate systems are in place to ensure the welfare and heath & safety of service users and staff. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holicote Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000038029.V267647.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes. 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 YA37 Regulation 8 Requirement As highlighted in previous inspection reports, the registered manager must be in full-time day-to-day control of the home. Written assurance is required as to the intended future management arrangements for Holicote, which must be submitted together with a copy of any job descriptions for the role, setting out how this requirement is to be met. Timescale for action 01/04/06 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. Refer to Standard YA6 Good Practice Recommendations As highlighted in previous inspection reports, where service users remain in the home for longer periods, more detailed care plans should be developed. Care plans should identify individual needs, goals and aspirations; highlight the specific action / interventions required and being taken to meet such needs; and record ongoing monitoring and reviews. In such circumstances a key-worker should also DS0000038029.V267647.R01.S.doc Version 5.0 Page 21 Holicote 2. YA9 3. YA17 be appointed. As highlighted in the previous inspection report, although within the homes care planning arrangements general risk assessment documentation is being used, specific risk assessments for individual service users should also be developed in greater detail. As highlighted in the previous inspection report, records of food supplied should contain more detail. Holicote DS0000038029.V267647.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 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.V267647.R01.S.doc Version 5.0 Page 23 - 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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