Inspection on 16/11/07 for Holland House

This inspection was carried out on 16th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holland House 08/08/06

Holland House 01/11/05

Holland House 18/04/05

Holland House 12/08/04

Holland House 26/04/04

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Southfields

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

CARE HOME ADULTS 18-65 Holland House Holland House Coulsdon Road Caterham Surrey CR3 5YA Lead Inspector Mike Murphy Unannounced Inspection 16th November 2007 10:00 Holland House DS0000013676.V349865.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 Holland House DS0000013676.V349865.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. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holland House Address Holland House Coulsdon Road Caterham Surrey CR3 5YA 01883 383715 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) Dennies.ward@sabp.nhs.uk Surrey and Borders Partnership NHS Trust Mrs Dennies Donicia Ward Care Home 10 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (7) of places Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: Holland House is owned by Surrey and Borders Partnership NHS Trust and is located in The Trust’s grounds in Caterham. It is one of a number of purpose built bungalows and is designed to accommodate up to ten service users with a learning difficulty. The home is just over two kilometres from Caterham station. The area is served by buses travelling to Redhill and Croydon. There is no pressure on parking in the vicinity of the home. There are a number of shops within relatively short walking distance and a larger shopping centre in Caterham. Accommodation includes ten single bedrooms without en-suite facilities. There is also a large lounge, smaller lounge, dining room, and ample toilet and bathroom facilities. The bungalow is set in its own grounds with its own garden and patio. There is easy access to the local community facilities. The home has its own transport. The fees charged at the time of this inspection were from £904 to £1038 per week. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector in November 2007. The inspection included discussion with the care team leader (the registered manager was on leave), staff and service users, observation of practice, a visit to the home, consideration of information provided by the manager in advance of the inspection, consideration of CSCI survey forms returned in connection with the inspection, examination of records (including care plans and staff records), and a tour of the home and garden. Although the home has not recently admitted a new service user it has systems in place for assessing the needs of a prospective service user and for ensuring that it can meet those needs. The home’s care planning processes are thorough and aim to ensure that care and support is provided in accordance with the wishes of the service user. Documentation to plan, support and record care planning is comprehensive. The documents include a person centred plan (PCP) in which the detail of care is recorded. The home has some very good practices in making documents more accessible to service users and it might therefore, consider separating the PCP from the main file with the aim of making it a more ‘user friendly’ working document. That said, the standard of written documents is good. Service users lead a varied lifestyle and each has a diary for the week. The diary is in picture as well as text presentation. Service users go shopping with staff in Caterham and in the larger centres of Redhill and Croydon. Some go to art and music therapy and a local centre offers opportunities for participation in handicrafts, music and movement, dancing, cookery, gardening and language skills. Service users and staff have recently participated in an ‘anti stigma’ week event and a service user recently successfully completed the charity run ‘Race for Life’. Meals are prepared in the home and the menu is drawn up in consultation with service users and a dietitian. Arranging for looking after the health of service users are satisfactory. All are registered with a local GP practice and the home liaises with a range of community health services in supporting the health care of service users. The home’s policy for complaints and its policy, staff training and guidance on safeguarding vulnerable adults are good. Service users have regular contact with an advocacy organisation. The environment is satisfactory. Since the last inspection areas of the home have been redecorated in consultation with service users, and on this inspection the home was well decorated, clean and tidy, and provided a safe and comfortable place for service users to live. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holland House DS0000013676.V349865.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 Holland House DS0000013676.V349865.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. The needs of prospective service users are assessed before admission to ensure the home can meet the person’s needs. EVIDENCE: The home has not had an admission since the last inspection. It had one vacancy at the time of this inspection. The care team leader said that a prospective service user would be invited to view the home, meet staff and current service users over tea or coffee, and form an initial impression on whether the home was suitable. The home would have access to existing assessment information on the person. Both the visit and the information would inform the decision on whether the home is likely to be able to meet the person’s needs at this stage. Where the referral is progressed, the prospective service user would be invited for a further visit - this time to include joining current service users for a meal – and would gradually extend to a trial admission. During this time the home would acquire further information on the person and conduct its own assessment of the person’s needs. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 9 A review meeting involving the person, his or her family, staff, the referring care manager, and perhaps other professionals involved, would be held after six weeks. A decision on whether the home can meet the person’s needs and whether he or she is settling in to the home would be made at that meeting. Holland House DS0000013676.V349865.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive care plan is in place for each service user. Care plans include details of how the service user prefers care to be provided and of risk assessments. The views of service users are sought through day-to-day encounters in the home. Together, these activities aim to ensure that service users needs are met, that their independence is supported, and that care is provided in line with the person’s wishes. EVIDENCE: A care plan is in place for each service user. Care planning is co-ordinated by senior care workers acting as key workers. The content of care plan documents is comprehensive and of good quality. However, the structure is complex and not particularly accessible to service users given the specialist nature of this service. The ‘Person Centred Plan’ (PCP) forms part of a larger document. The home has some very good practices in making documents accessible to service Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 11 users and consideration might be given to separating the PCP from the main file to make it a more accessible ‘user friendly’ working document. The PCP section outlines the ‘essential things’ required to provide care, the ‘things enjoyed’ by the service users, the ‘things that matter’ to the service user, and a ‘communication chart’. Each section lists a number of activities and the support which the service user needs. The ‘essential things’ section is primarily concerned with personal care: bathing, shaving, medication, meals and toileting. The ‘things enjoyed’ lists matters of importance to the service users such as: music and TV, outings going to a day centre, aromatherapy and use of wheelchair. The ‘things that matter’ again relate to personal care such as: position in bed, undressing and dressing, tone of voice and rate of speech, and clothing. The ‘communication chart’ lists some aspects of the service user’s behaviour, what it might mean, and what staff should do in response. Care plans support the provision of appropriate care to service users and reflect the preferences and choices of individuals. Care plans are reviewed every six months - more often where necessary – a typed summary of the review is placed on file. Records of multi-agency reviews were also noted. PCPs included a relationship circle – a series of concentric circles with the service user in the centre and the position of people known to the service user (e.g. family, friends, staff) positioned according to their relationship to the person. PCPs also included a ‘need to know’ section i.e. a list of essential information for those providing care to the person. Service users are involved in decision making though day to day interactions with staff and other service users, care planning, consultation on activities (such as outings), and through home meetings. Risk assessments cover a range of activities including the risk of falls, risks associated with going out, manual handling, risks related to the use of appliances, harm to self or others and of exploitation. Holland House DS0000013676.V349865.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, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents lead a varied lifestyle according to their individual interests, abilities and wishes. This ensures that service users have experience of a range of social, leisure and other activities and are involved with the local community. EVIDENCE: There were nine service users in the home on the morning of the inspection visit. Four were in the lounge, one had gone to art therapy, one had gone to an advocacy group meeting, two had gone into town with staff, and one wished to stay in her room. In the evening a small group were going with staff to a concert in Redhill. Service users go shopping with staff in supermarkets in Caterham, shopping for clothes and other things in Redhill or Croydon, and use local cafes and pubs. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 13 Two service users had recently had a week’s holiday with staff in Kos, Greece, two had been to Butlins in Bognor Regis during the summer, and two more were due to go to Bognor Regis in December. Some service users had also been to London for a night out i.e. a meal followed by a show. Most service users are in touch with their families and are supported by staff as required in maintaining contact. Staff and service users recently participated in an ‘anti stigma’ week aimed at ensuring that the principles of equality and diversity are translated into practice. Photographs of the event were on file in the home. Of particular note also this year was the participation of one service user in a cancer charity event, the ‘Race for Life’, at the end of which she received a medal and of which she is deservedly proud. The person concerned said that she was quite happy living in the home. Over the summer period the manager reports that the home had a barbeque and invited friends and relatives. Some service users go to a local centre and participate in activities such as handicrafts, cookery, gardening, language skills, dancing and music and movement. Music therapy is held once a week. Aromatherapy is provided for those who would like it. The home has a daily routine which seems to suit those living there. Each service user has an activity diary in text and picture form. Service users are supported in personal care as required. Breakfast, which on weekdays is usually cereal, toast, juice and hot drinks is taken between 7.30 and 9.00 am. A cooked breakfast is served at weekends. Service users then follow their diary for the day – this may involve going to a regular day activity (such as art therapy), going into town with staff, or pursuing their own interests in the home. Lunch, which is usually sandwiches or a savoury snack, soup, yoghurt and drinks, is taken around 12.30. In the afternoon, service users again follow their planned activity. The care team leader said that they always try to ensure there is a driver available on each shift so that people can have a trip out or go shopping as they wish. Again, others have time pursuing their own interests in the home during this period. The ‘Evening Meal’ is served around 5.30 pm and is a two course meal consisting of main course and dessert. Sample choices from the summer menu (June to December) included: Chicken Curry, Rice and Salad followed by Fresh Fruit Salad; Lamb Stew, Boiled Potatoes, Peas and Carrots followed by Stewed Fruit and Evaporated Milk; Pork Chops, Boiled Potatoes, Brocolli and Green Beans followed by Banana Custard. Fish is served on Fridays and a meat joint (such as a roast) on Sundays. After tea, some might go out for a while (as to the concert in Redhill on the day of the inspection visit) while others watch TV, listen to music or pursue other interests in the home. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 14 Menus are drawn up in consultation with service users and a dietitian. Service Users with particular dietary needs (such as those who may have difficulty in swallowing) are seen by the dietitian and special diets or supplements prescribed. Service users are not routinely weighed. Holland House DS0000013676.V349865.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): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide support to residents as required. Arrangements for liaising with health and social care services in the community are good. Arrangements for the control and administration of medicines are generally satisfactory. Together, these aim to ensure that service users healthcare needs are met. EVIDENCE: Support to service users is co-ordinated through the home’s care planning and key working systems. A group of staff have worked with the service users for a number of years and have knowledge of their preferences. The detail of service users needs and preferences are recorded in their PCPs and other documents – in particular the ‘Health Action Plan’. All service users are registered with a GP service in Old Coulsden. A chiropodist visits every six weeks. At the time of this inspection one service user had been referred to a physiotherapist in Redhill - the physiotherapist visits the home. Opticians are available in Catherham. There is a dentist on site. The dietitian is based with the community team in Redhill. The home is in touch with a Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 16 number of care managers based in community learning disability teams (CLDTs) including those located in Croydon, Wandsworth and Eastbourne. Medicines are prescribed by the GP and dispensed by a local pharmacy in Kenley (near Purley). Arrangements for the storage of medicines are satisfactory but will improve when a new cupboard, which was on order around the time of this inspection visit, is delivered. Medicines requiring cool storage are stored in a separate container in the fridge. However, this is not lockable and the care team leader said that lockable containers will be acquired. Staff practice is governed by the policy of the organisation. The home has a homely remedies policy but the copy examined had not been signed by a doctor or pharmacist. Basic and update training is provided by an NHS pharmacist. The care team leader said that staff are required to administer medicines at least five times under supervision by the manager before being considered competent to administer medicines to service users. Regular checks are made on stocks of medicines and the home has a very good record sheet for recording its weekly check of medicines. The supplying pharmacy does not carry out a periodic audit. A British National Formulary (BNF)is available as a reference to staff. It would be advisable for the home to obtain a copy of the most recent edition of the Royal Pharmaceutical Society of Great Britain guidelines on medicines in social care (published in October 2007), and CSCI guidance on this subject. The medicines record for each service user includes: basic information, a copy of the repeat prescription, a medicines administration record (‘Mar chart’), consent form to medicines, and where applicable, a record of rectal diazepam administered and a seizure chart. Examination of MAR charts found no errors or omissions. The balance of the home’s stock of Lorazepam corresponded with records when checked. Some external preparations (i.e. creams) had not been dated when opened. A green ‘as required’ (‘PRN’) medicines sheet had been left on the persons medicines file even though ‘PRN’ medicines were not currently prescribed. This practice should be reviewed and consideration given to filing such records in the resident’s main file when such medicines have been discontinued. Holland House DS0000013676.V349865.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): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a policy and procedure for recording and investigating complaints. It has a framework of policy, reporting arrangements and staff training with regard to the protection of vulnerable adults (POVA). Together, these aim to protect service users from abuse and to ensure that complaints are properly investigated. EVIDENCE: The home has a complaints procedure in place. This is available in text and picture format. Systems are in place for recording complaints. No complaints have been received since the last inspection. CSCI has not received any complaints about this service during this period. On examination of records it is noted that the home had received written compliments since the last inspection. One relative respondent to the CSCI survey carried out in connection with this inspection indicated that they did not know how to make a complaint about the home. In the survey the same respondent reported that the home ‘usually’ ‘responded appropriately’ when concerns have been raised about the care of their relative. A policy and procedure is in place for safeguarding vulnerable adults. The policy folder includes a copy of an informative presentation in January 2007 by an advocacy organisation to an inquiry into alleged abuse in a neighbouring authority in the South East. All staff have received training in the subject of Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 18 safeguarding adults. Staff spoken to during the course of the inspection said that they had never witnessed abuse of any form in the service. A copy of the Surrey statutory multi-agency policy on safeguarding adults was available in the home. The home appears to have close contact with an advocacy organisation, the ‘Surrey Advocacy Alliance’. Advocates were said to visit service users in the home and some service users attended a meeting by the organisation in another home on the site. Holland House DS0000013676.V349865.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): 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an accessible, pleasant and well-maintained environment which provides those living there with a comfortable and safe place to live. EVIDENCE: The home is a detached bungalow set in the grounds of what was formerly a hospital. Some of the premises elsewhere on the site are also managed by the same Primary Care Trust (PCT). The home is just over two kilometres (uphill) from Caterham station. The area is served by buses travelling to Redhill and Croydon. There is no pressure on parking in the vicinity of the home. There are shops in the locality - a relatively short walk from the home, a larger shopping centre in Caterham, and main shopping centres in Redhill and Croydon. The accommodation consists of ten single bedrooms, each with a hand basin. There is one lounge, one dining room and a quiet room. There are two bathrooms, one of which has an assisted bath (Arjo bath with chair lift). There are fours WCs. There is one kitchen, one laundry and utility room, and one Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 20 office. All areas are accessible to wheelchairs. There is a garden to the rear and side of the building. The building can be adapted as necessary to meet the needs of frail service users. All areas of the home were clean and tidy on the day of the inspection visit. Bedrooms vary in size, are comfortable, well furnished and pleasantly decorated in accordance with the wishes of the service user. Many areas of the home have been redecorated since the last inspection and new curtains were being put up in the lounge on the morning of the visit. According to the registered manager new carpets, sofas, a coffee table and pictures have been provided in the lounge. The dining room has been repainted and new pictures have been put up. New flooring has been laid in the hallway and corridors. The kitchen had been repainted and new blinds put up. Overall, the home environment presents a bright and clean image and a positive impression. There appears to be sufficient shared space in the home for the current needs of service users, although one person felt that it can get overcrowded at times. The dining room comfortably accommodates service users at mealtimes and it was noted that it is used by service users and staff at other times as well. The lounge is sufficient in size for current needs and was used by service users throughout the day of the visit. The quiet room is a small room which is occasionally used for individual or small group activities. The kitchen was clean, tidy and in good order. The report of a visit to the home by a Health and Safety inspector of Tandridge District Council in May 2007 was seen and it is noted that no recommendations were made. The laundry room is suitably equipped for current use and the washing machine was reported to have sluicing and high temperature programmes. The garden comprises areas of lawn, bordered by shrubs and flowers, and is enclosed with fencing. It has areas for seating, a barbeque and a dining area with table and chairs. Holland House DS0000013676.V349865.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): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, procedures for the recruitment of new staff, and for staff training, development and support are satisfactory. These aim to ensure that there are sufficient numbers of appropriately trained and supervised staff to meet the needs of people receiving support from the service EVIDENCE: The present staffing of the home provides for three staff in the morning, three in the afternoon and evening, and two waking staff at night. These levels may be supplemented when required – such as the need to provide additional oneto-one support on occasions. The staffing comprises the registered manager, one care team leader, six senior support workers, and two support workers. There is a good level of stability within the staff team and most have worked with the service users for many years. The manager and team leader are registered nurses. The senior support staff have all acquired NVQ2 at a minimum. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 22 The home is supported in the recruitment of new staff by the organisation’s Human Resources department. No new staff have been appointed since the last inspection and the care team leader said that there were no vacancies at that time. The manager reports that background checks are carried out on all applicants including previous employment and enhanced CRB checks. The home occasionally uses an agency in Sutton. The agency provides a photograph, details of training, recruitment, and that a CRB check has been obtained on staff provided. Staff have access to a comprehensive and ongoing training programme run by the Trust. Training takes place in Epsom, Oxted and on site. This is supplemented in the winter and spring by training offered by Surrey County Council. However, staff report that on occasions the location of training events is not convenient for the home, that events are sometimes cancelled at short notice and that demand for training events exceeds supply leading to a waiting list. Training includes: Health & Safety, Food Hygiene, Disability Awareness, Makaton, Safeguarding Adults, First Aid, Administration of Medicines, Cognitive Behaviour Therapy ‘Compulsive Hoarding and Acquiring’, Moving and Handling, Epilepsy Awareness, Records and Reporting, Dementia Awareness, Parkinson’s Disease, Skills for Care Induction, and Staff Supervision and Performance. Each member of staff has an individual folder containing details of supervision, a learning styles questionnaire, appraisal, personal development plan, ‘job outline’, the GSCC codes of practice, training records (noted that this included training on ‘Mental capacity Act’ and ‘Implementing Positive Behavioural Support Plans’), and certificates of attendance or completion of training events. All staff have personal supervision. This takes place monthly. Records are maintained. The manager is reported to be supportive to staff. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is generally a well managed home where a positive approach to the care of service users is providing good care outcomes for the people it serves. Arrangements for health and safety are generally thorough and aim to ensure the safety of residents, staff and visitors. However, some records were not readily available at the time of the inspection visit so the home was not able to provide evidence of all activity. EVIDENCE: The registered manager is a registered nurse (in learning disability) and holds the Registered Manager’s Award (RMA) and is a qualified assessor. The manager has had many years experience in managing services for adults with Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 24 a learning disability and has had experience in services caring for older people and for children. The home’s approach to quality assurance is comprised of Regulation 26 visits, a network of meetings with service users, and staff meetings. The home had not carried out a stakeholder survey in 2007. The notes of recent Regular 26 visits were examined during the course of the inspection visit. The visits are carried out by manager’s from other homes and the records of such visits include: progress from previous Reg 26 visits, action on CSCI inspections, views of service users, checks on records (including finance, care plans and medication records), health and safety, and staff training and development. The notes of the October 2007 visit were particularly informative and comprehensive. It is noted that the notes of some meetings include references to targets for service user activities (e.g. residents to have seven whole day trips a year and residents must have three individualised activities outside the home each week). It is also noted that the notes of service user meetings include colour pictures relevant to the matters discussed – a very good practice. Reference to an annual quality assurance and development plan was noted on a form but had not been completed. The home has a health and safety policy and there are procedures in place for monitoring its health and safety arrangements. Quarterly health and safety checks are carried out by the organisation’s works department. Arrangements are in place for staff to receive basic and periodic update training in health and safety. The home’s arrangements for fire safety appear generally satisfactory but records were not available to provide evidence of all activities. Fire safety arrangements were reported to be carried out under the authority of the fire safety officer. A fire risk assessment is mentioned in the index to the home’s records but a copy of the most recent written assessment was not on file. The care team leader said that the home is checked quarterly to ensure that its fire safety arrangements are satisfactory. According to records seen on this inspection visit, staff last attended fire training in June 2006. Arrangements are in place for contractors to carry out checks and maintenance on smoke detection, emergency lighting and fire fighting equipment. Portable electrical appliances had been checked in September 2007. Records of contractor’s checks on the home’s fixed electrical wiring, gas appliances and on its hot water systems (for Legionella) were not available in the home at the time of the inspection visit. Risk assessments covering a range of activities were on file. Procedures are in place for recording accidents. Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 25 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The registered manager should consider whether the PCP section of service user files should be more clearly separated from the person’s main file with the aim of developing a more ‘user-friendly’ working document. The registered manager should ensure that staff label external medical preparations when opened. The registered manager should obtain the signature of a GP – and that of a pharmacist if practicable – on the home’s ‘Homely Remedies’ policy. The registered manager should ensure that records of conformance to all aspects of health and safety are available for inspection in the home. 2 3 4 YA20 YA20 YA42 Holland House DS0000013676.V349865.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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