Inspection on 24/11/06 for Holicote

This inspection was carried out on 24th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holicote 10/12/07

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 Mr Paul Emmerson Unannounced Inspection 24 & 28 November 2006 08:30 th th Holicote DS0000038029.V319529.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.V319529.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.V319529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holicote Address 93 Newton Lane Darlington Durham DL3 9HH 01325 287831 01325 287831 glenys.hilary@darlington.gov.uk 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.V319529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 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. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours, on the morning and afternoon of Friday 24th November and the morning of Tuesday 28th November 2006. In line with current CSCI policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. The inspector looked around the building and a number of records were examined. The home’s manager, 6 members of staff and a visitor were spoken to. CSCI questionnaires and comment cards about Holicote were also sent out. Within the limits of their communication and understanding, service users were also spoken to. CSCI is trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. For part of the inspection an ‘expert by experience’ visited Holicote. Her comments have been used in writing this report. What the service does well: What has improved since the last inspection? Since the last inspection, ceiling / track hoists have been fitted in 2 bedrooms and an adjustable height bath has been fitted in the main bathroom. This equipment has been put in to assist people with physical impairments, in particular people who use wheelchairs. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 6 To improve continuity of care, the home’s staff complement has been reviewed. More full-time / permanent staff are now employed, including a new team-leader. The home’s office has recently been rearranged and refitted to make better use of the space available. Policies and procedures for Holicote have been reviewed to create more service specific policies, procedures and guidelines for the home. The significant amount of work required to do this is acknowledged. 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.V319529.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 Holicote DS0000038029.V319529.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home are appropriately managed. EVIDENCE: Holicote provides respite care for adults (aged 18 – 65) with learning disabilities. Service users with physical impairments can also stay at the home. Any short-break stays arranged are for an agreed duration, which can be overnight stays or for a shorter length of time, for example to stay for a meal. People can use Holicote after an assessment of need and recommendations following a multi-disciplinary team review. Access and the level of support currently provided is determined by Darlington learning disability service’s eligibility criteria, which is being reviewed to ensure ‘fair access’ to services. From observations made during the inspection, and from discussions with service users, management and staff, Holicote provides a good standard of care. 56 people are currently using the service. Service users’ needs and aspirations are appropriately assessed and relevant information is provided to the home on, or prior to, admission. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 9 Service users are admitted via referrals through care co-ordination processes involving relevant health and social care professionals; who provide the home with assessments of need and care plan documents. An information gathering questionnaire (‘information about yourself’) is also given to each new service user and their carer to fill out. Individual service user plans, sufficient to inform the delivery of care to service users during their stay, are then developed. Service users considering a stay at Holicote would be welcome to visit the home with their relatives, have a meal and stay overnight if necessary. In this way service users can get to know the home before staying for longer. The ‘expert by experience’ who visited Holicote thought that the home and staff, “Were welcoming. Staff were friendly and had good communication with each other”. A Statement of Purpose, a Service User Guide and other information leaflets in pictorial formats are available to provide service users and their families with information about the home. Upon admission a terms and conditions agreement, which is also in a pictorial format, is written out. Holicote DS0000038029.V319529.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): 6, 7 & 9. 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 are met by the home. 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: Care plan information, sufficient to inform the delivery of care during any stay is available. 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. The ‘expert by experience’ who visited Holicote said, “Each service user has their own file including the care plan. It is the staff’s responsibility to read care plans before starting their shift”. As staff get to know individual service users, care planning arrangements are developed to ensure individual needs and aspirations are met. Additional assessment information, through links with care co-ordinators and other Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 11 professionals, informs ongoing care planning in the home. Any changes to care plans are thus considered. Since the last inspection, key-working arrangements have been developed. The ‘expert by experience’ who visited Holicote noted that, “Service users are shared between on duty staff, there is a display board in the office which indicates this”. Although some service users stay at Holicote for longer periods of time, most people stay for short breaks. Holicote thus fits within the overall community support, services and lifestyle arrangements for service users and their families. Decisions about lifestyle choices generally fall outside the direct responsibility of the home. However, when service users stay at Holicote any existing social, recreational, educational or employment arrangements are followed. Any decisions about risk are also considered within overall care co-ordination arrangements and the inspector saw general risk assessment documentation on each of the care plans examined. However, specific risk assessments for individual service users must also be developed within the home’s care planning arrangements. In particular for people with high levels of need, as is the case with a number of people now using the service following the closure of Darlington’s Greenbank respite care unit. Individual / specific risk assessments must be completed and more detailed risk management plans must be put in place as a matter of urgency. Holicote DS0000038029.V319529.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): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff permitting, activities are arranged. Service users come to use the service from their local community. Contact with family / friends is supported. Meals are wholesome and nutritious. All dietary needs are met. EVIDENCE: Any activities arranged fit with service users’ usual routines and lifestyles. On the morning of the inspection a number of service users went to day care placements. The night before, some people went to Darlington’s Gateway Club. When asked if he’d enjoyed this visit a service user replied, “Yes, I liked dancing”. Two people with Learning Disabilities are employed by the home. Both these people were spoken to. Both enjoy their work. One person said, “I love having a paid job.” A relative spoken to on the day of the inspection said. “It’s brilliant, absolutely fantastic, first-class. It’s just there’s not enough respite care in Darlington. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 13 When service users stay over the weekend, activities are also arranged. However, current staff arrangements are limiting the scope of what can be achieved or organised. Further, although the home has access to a mini-bus, shortages of staff able to drive the mini-bus mean it is an underused resource. The ‘expert by experience’ who visited Holicote said, “Leisure outings are limited to walking to the local shop and a trip to the ‘Gateway Club’ on a Thursday night. Service users would benefit from choosing where and what they wish to do with their time”. Respite care services exist to provide short-term breaks to ensure family support can continue. When people stay at Holicote, wherever possible family and other relationships are supported. Documents in the home show that a four-week menu is used; records of food supplied are kept. When required, special diets are supplied and where necessary staff give service users assistance with eating. The evening meal served on the day of the inspection was of a good standard. Alternatives to the menu were available. However, more could be done to let people know about these food alternatives. The ‘expert by experience’ who visited Holicote said, “A visible and accessible menu giving choices in both writing and pictures would benefit the service users”. Holicote DS0000038029.V319529.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): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although risk assessments need to be completed, 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 each person’s stay. Where necessary, the home arranges 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. Where personal support is required it is given appropriately. Service users are provided with guidance and encouragement to ensure their needs are met, thus promoting independence in a dignified and respectful manner. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 15 In a CSCI inspection questionnaire a relative said, “Staff are very supportive with healthcare and medical needs. The attitude of staff is by far the most important factor”. 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 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 it is acknowledged that general risk assessments about the home have been done, individual risk assessments have not. A number of people now coming to Holicote have much higher levels of need. These people require specialist equipment and more complicated moving and handling techniques. As highlighted under Standard 9 above, individual / specific risk assessments must be completed and more detailed risk management plans must be put in place as a matter of urgency. 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 plans. Holicote DS0000038029.V319529.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): 22 & 23. 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. 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 a CSCI inspection questionnaire a relative said, “Any problems I have are sorted out with staff face to face.” A pictorial version of the home’s complaints procedure is also available. Information about the home’s complaints procedure and contacting CSCI is written in the home’s A-Z Service Users’ Guide. 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. 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.V319529.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holicote was purpose built. It is homely, well-maintained, safe and clean. 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. 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. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 18 The inspector and the ‘expert by experience’ looked around the building, which was found to be 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. Since the last inspection, ceiling / track hoists have been fitted in 2 bedrooms and an adjustable height bath has been fitted in the main bathroom. This equipment has been put in to assist people with physical impairments, in particular people who use wheelchairs. 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. The ‘expert by experience’ who visited Holicote said, “The dining room can be very full and service users could have benefited from more room or other dining space to be able to move around freely”. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate staffing arrangements are in place. EVIDENCE: Due to the diverse needs of the 56 people who currently use Holicote, staffing levels need to be, and are, flexible. 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 / permanent staff are now employed, including a new team-leader. However, the service still relies heavily on bank / pool staff from other areas of the learning disability service. To ensure that staff can meet the increased needs of the service users now coming to Holicote, it is recommended that the number of permanent staff should be increased. 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. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 20 Two written references are obtained before employment can commence along with 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. Staff training and development is afforded high priority. All permanent staff have NVQ (National Vocational Qualifications) at level 2 or above. The ‘expert by experience’ who visited Holicote said, “Staff have a varied rolling training programme… Staff hold team meetings”. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although Holicote runs well, a permanent, full-time manager is needed. EVIDENCE: Holicote is run by Darlington Borough Council’s (joint health and social services) learning disability service. The current registered manager has an NVQ level 3 qualification in care (promoting independence) and in June 2005 completed the registered managers award (NVQ level 4). She has lots of experience of working with people with learning disabilities. However, management jobs within the local authority were reviewed last year. As part of this review, the manager got a more senior post as Community Inclusion Officer for Short-Term Breaks and Supported Living. However, because a new manager for Holicote hasn’t been appointed yet, the current manager has to do 2 jobs. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 22 Although it is acknowledged that the current manager is doing her best and has made a number of significant improvements to the service, Holicote needs its own, separate manager and so to does the supported living service. As highlighted in previous inspection reports, the registered manager must be in full-time day-to-day control of the home. A new manager for Holicote should be appointed as soon as possible. The home through the local authority has a range of appropriate policies, procedures and guidance 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 have been reviewed to create more service specific policies, procedures and guidelines for the home. The significant amount of work required to do this is acknowledged. 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. Service users’ and families’ views are obtained through ongoing contact and an ‘open door policy’. Coffee morning meetings have been held, which have provided an additional forum to discuss any concerns or potential difficulties. The manager also spoke about a meeting with service users and families that has been arranged by senior managers to discuss respite care services in Darlington. However, to ensure more people’s views about Holicote are obtained, it is recommended that the service should consider sending out and analysing quality assurance questionnaires to service users, families etc. The ‘expert by experience’ who visited Holicote also said, “A meeting for service users staying at Holicote to discuss planning activities, choice of meals etc. would ensure user involvement”. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 23 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 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13 Requirement Specific risk assessments for individual service users must be developed within the home’s care planning arrangements. In particular for people with high levels of need. Timescale for action 01/04/07 2. YA37 8 01/04/07 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. The previous timescale of 01/04/06 was not met. Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 25 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 YA7 Good Practice Recommendations Service users would benefit from choosing where they go, and what they wish to do, with their spare time. A visible and accessible menu giving choices in both writing and pictures would benefit the service users. A meeting for service users staying at Holicote to discuss planning activities, choice of meals etc. would ensure user involvement. The service still relies heavily on bank / pool staff from other areas of the learning disability service. To ensure that staff can meet the increased needs of the service users now coming to Holicote, it is recommended that the number of permanent staff should be increased. To ensure more people’s views about Holicote are obtained, it is recommended that the service should consider sending out and analysing quality assurance questionnaires to service users, families etc. 2. YA33 3. YA39 Holicote DS0000038029.V319529.R01.S.doc Version 5.2 Page 26 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.V319529.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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