Inspection on 26/04/06 for Holly Cottage

This inspection was carried out on 26th April 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

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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 Holly Cottage 1 Mill Lane Balcombe Nr Haywards Heath West Sussex RH17 6NP Lead Inspector Mrs M McCourt Key Unannounced Inspection 26th April 2006 13:30 Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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 Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holly Cottage Address 1 Mill Lane Balcombe Nr Haywards Heath West Sussex RH17 6NP 01444 811630 01444 811630 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) Evesleigh Care Homes Limited Ms Patricia Margaret Hyland Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 4 service users in the categories listed above may be accommodated at any one time. New registration Date of last inspection Brief Description of the Service: Holly Cottage is a care home registered to accommodate up to four Service Users with learning disabilities. The Registered Provider is Evesleigh Care Homes Ltd and the Registered Manager is Ms Pat Hyland. The current scale of monthly charges ranges from £1,000 to £1,300. This information was provided on the pre-inspection questionnaire. Additional charges are made for personal items, such as; toiletries, clothing and so on. The home is a semi-detached property, situated in a small rural village in Balcombe, which is situated between Haywards Heath and Crawley and therefore has access to all community facilities and is within easy reach of local rail and bus stations. Accommodation is provided over two floors. Each resident has their own bedroom, with a bedroom located on the ground floor, and the remaining three rooms on the first floor. On the ground floor there is a living room, an activity room and a large kitchen that includes a dining area. In addition the home has a garden with lawn and decking to the rear of the property. The Service Users Guide and Statement of Purpose, which incorporates inspection reports, are both located at the home and are accessible to Service Users, staff, relatives and anyone else interested in the service. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken on Wednesday 26th April 2006 and lasted a total of five hours. Pre-inspection planning took approximately two days. A full tour of the building took place and included the observation of Health and Safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Three staff members, one resident, and the Registered Manager were spoken to at the time of inspection. Following the site visit the Inspector spoke with a relative of one of the Service Users. Case tracking was carried out by examination of relevant records and information held on the staff and residents spoken with during the course of the inspection. The overall outcome for Service Users was excellent. What the service does well: The home provides good, clear information regarding the abilities and disabilities of the residents, with specific guidance on how best to support individuals. Personal likes and dislikes are recorded and goal planning works towards specific achievements for individuals. Regular reviews are held and Service User input is sought and recorded. Minutes of reviews were found to be very comprehensive. Families and relevant health professionals are invited and encouraged to contribute to the overall wellbeing of Service User. Service Users are assisted to access the local community and take part in relevant activities. One resident told the Inspector that he enjoys his parttime job at the local school, where he is employed to carry out maintenance work. The Inspector carried out a tour of the premises. The home was found to be in an excellent state of decoration. Fixtures and fittings are in very good order and the environment is very homely and comfortable. A new kitchen has been fitted within the last eighteen months. The Inspector spoke with a relative of a Service User who said she often calls at the house without prior appointment, and that the home is always clean and tidy. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 6 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. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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 Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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): 2, 4 and 5 The outcome for Service Users was found to be good. Service Users are consulted about where they choose to live prior to moving, and are certain that the home will meet their individual needs. EVIDENCE: The home has an admissions/referral procedure that clearly states the process to be followed when considering a Service User’s placement. Service User’s personal files were examined during the inspection and found to contain detailed pre-admission assessments. Care plans are compiled from the assessment process and included risk assessments; individual care needs and personal preferences. Personal files contained signed contracts of care. Discussion with the Registered Manager confirmed that thorough processes are in place regarding admission to the home. There are currently two vacancies, with some interest from prospective Service Users. Initial visits have been made and the Registered Manager said that tea visits, overnight and weekend stays will be offered as part of the progression. It is of particular importance that prospective Service Users are carefully placed in order to fit in with the complex needs of one of the Service Users already living at the home. Following the site visit the Inspector spoke with a relative of a Service User, who also confirmed the need to place prospective Service Users carefully in order to keep the equilibrium within the house. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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): 6, 7 and 9 The outcome for Service Users was found to be good. Service Users needs and personal goals are reflected in their care plans. Service Users are assisted to make decisions about their own lives, which includes taking responsible risks. EVIDENCE: The Inspector examined two individual care plans as part of the case tracking process. Those seen provided good, clear information about the abilities and disabilities of the resident, with specific guidance on how best to support the person. Regular reviews are held and Service User input is sought and recorded. Families and relevant health professionals are invited and encouraged to contribute to the overall health and welfare of the Service User. The Inspector spoke with one of the Service Users in order to obtain his views on life at the home. It was confirmed that with guidance and support from the staff he is able to make decisions about his life and to take risks as part of Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 10 achieving an independent lifestyle. The Inspector was told by the Service User that he regularly went out into the community to enjoy various leisure activities, such as; visiting local tearooms, visiting friends and walking into the local town. Minutes of review meetings show that the meetings are inclusive of health care professionals, relatives/family members, Service Users, staff and Care managers. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 11 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): 12, 13, 15, 16 and 17 The outcome for Service Users was found to be excellent. Service Users are able to take part in a range of appropriate activities within the local community. Service Users are supported with family relationships and guided to develop personal friendships. Meals are varied and nutritious. EVIDENCE: Service Users are encouraged to access the community through involvement in various leisure activities and by participating in workshop programmes, arranged by Evesleigh Care Homes. During the inspection, one of the Service Users returned from attending his workshop programme and told the Inspector what he had been doing that day. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 12 He attends a workshop twice a week where he makes different items; on this particular day it was bird boxes. The resident also enjoys his part-time job at the local school on Wednesday afternoons, where he is employed to carry out maintenance work. Service Users are encouraged to pursue individual interests and hobbies, and within the home they are able to choose from watching T.V., listening to music, reading and so on. The activity room within the house is being used by both Service Users to access the computer located there or play music, and one regularly uses it as a quiet/time out room. A Service User told the Inspector that he likes typing letters to his mum on the computer. Personal files show how Service Users are assisted to access the local community and take part in relevant activities. Personal likes and dislikes are recorded and goal planning works towards specific achievements for individuals There were positive comments about the food, with a resident telling the Inspector that he likes cauliflower cheese which he is able to make with staff assistance. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 13 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 and 20 The outcome for Service Users was found to be good. Service Users receive personal support in an appropriate manner and suited to individual need. The home is able to provide physical and emotional care to individuals. Policies and procedures are in place to ensure the correct administration of medication. EVIDENCE: Personal records show details of healthcare appointments and also include the names and addresses of relevant professionals involved in individual care. Staff and Service Users have access to the Community Team for People with Learning Disabilities to assist with additional support and advice when required. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 14 The Inspector examined personal files for Service Users. Each file contained a contract of care, financial information, a personal profile, medical notes, dental records, psychiatric/psychology reports, funeral wishes, behaviour charts, sleep charts, weight charts, and so on. Monthly reports are carried out, and have been done consistently. Review reports, held in March 2006 were very comprehensive. The files also included Activity workshop detailed reports, which described various activities attended by the Service User. For example, visits to National Trust Gardens, trips out to the seaside/places of interest, indoor activities and so on. A keyworker system is in place. Staff told me how they help the Service Users with grooming, health appointments, activities and personal and/or family relationships. I was told how one member of staff has been working well with one of the residents and had recently been swimming. Afterwards they sat on the promenade eating fish ‘n’ chips. This is quite an achievement for the individual concerned. Medication policies and procedures are in place. However, medication is currently being sorted in a small filing cabinet that does not comply with regulations. On checking medication quantities, there was a discrepancy between the amount actually available and the amount recorded. This matter was double checked with staff present and we then found that the MAR sheet was also different to the reconciliation sheet. The Inspector was told that there is no formal reviewing system in place. The Registered Manager must review this issue to ensure medication is stored and administered in keeping with current regulations. In addition, from information obtained at the inspection, there is an outstanding issue regarding a Service User’s medication that clearly requires a conclusion. A review is due to be held with the psychiatrist. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 15 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 and 23 The outcome for Service Users was found to be good. Procedures are in place to ensure complaints are dealt with appropriately. Systems are in place to protect Service Users from abuse, neglect and selfharm. EVIDENCE: A complaints logbook was located at the inspection. This is stored in a separate file and contains the complaints policy. It has been updated to correctly show the name of CSCI and the new provider. It also includes a complaints record form, which the Registered Manager has implemented. A copy of West Sussex AP procedures was seen. There have been no complaints recorded at the home. Staff spoken with confirmed that they have received training in adult protection, and had a good level of understanding surrounding abuse issues. A resident told the Inspector that he knows who his keyworker is and if he had any concerns or complaints or wasn’t happy, would speak to this person. If the keyworker was unavailable, he said he would also speak to the manager of the home. A relative spoken with said that if she had any complaints she would contact the manager, following their procedure. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 16 Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The outcome for Service Users was found to be excellent. The home is clean, bright and in good decorative order throughout. Service Users live in a comfortable and safe environment. EVIDENCE: The Inspector carried out a tour of the premises. The home was found to be in an excellent state of decoration. Fixtures and fittings are in very good order and the environment is very homely and comfortable. A new kitchen has been fitted within the last eighteen months. There are currently two vacancies. The empty bedrooms have been nicely decorated prior to an admission. Communal areas consist of a lounge, the kitchen/diner and an activity room that is currently used by both Service Users. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 18 Outside there is a nice patio and decking area. The garden is in need of some attention after the winter, but there is certainly a good amount of useable space. A maintenance and renewal form is on disk for when the RM requires it. The Inspector spoke with a relative of a Service User who said she often calls at the house without prior appointment, and that the home is always clean and tidy. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The outcome for Service Users was found to be good excellent. A competent and qualified staff team is appropriately trained to meet the individual needs of Service Users. Recruitment policies and procedures are in place to ensure Service Users are protected from harm. EVIDENCE: Three members of the staff team were spoken to at the time of the inspection. I was told that there are regular staff meeting, every 4 to 6 weeks, where they are able to discuss any issue of concern. Minutes looked at by the Inspector show that health and welfare issues regarding individual Service Users are regularly discussed, and from this, action plans devised. Supervision is offered regularly and issues such as keyworking, personal and general work matters are discussed. Supervision is held monthly. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 20 Staff confirmed that they have attended the following training: 1st Aid, physical intervention, manual handling, medication, adult protection, autism, health and safety, food hygiene, epilepsy and how to use a fire extinguisher. The Inspector was told that mandatory training is updated either yearly or every three years depending on the requirement. Staff said that they feel well trained and if they wanted to attend a course they usually forward a request to the Registered Manager. Two of the staff members are just starting their NVQ level 3. A relative of a resident told the Inspector that she feels well informed by the staff team and does attend reviews. Recruitment information was examined and all staff files looked at contained CRB checks, two written references and all of the necessary information required to safeguard Service Users. Staff told the Inspector that they enjoyed being part of a small team. They said that they all work well together and feel like more of a family. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The outcome for Service Users was found to be good. Service Users benefit from a well run home, and are confident that their views form the basis for self-monitoring and development by the home. Service Users are protected by Health & Safety policies and procedures. EVIDENCE: The Registered Manager, Ms Pat Hyland, was recruited by Evesleigh Care Homes in February 2006. Prior to that she worked at South Down Housing for eleven years. She has obtained the Registered Manager’s Award and NVQ 4. Her background is working with people with severe disabilities and those with high health care needs. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 22 It was apparent that the Registered Manager has worked very hard in order to update all the files within the home, especially since there has not been a full time manager for a long period of time. She has revised and reviewed all documents and amended some to fit the specific requirements of the home’s staff team and Service User group. Staff told the Inspector that they were very happy with their new manager; they find her supportive, approachable and someone who gets things done when she says she will. They said that they feel there is more stability within the team now. A survey has just been conducted for Service Users, staff, care managers and next of kin. The results are to be compiled and published for the conference to by held on 2nd May 2006. A copy of the report is usually forwarded to CSCI. In addition, the Registered Manager told the Inspector that she is working towards holding ‘away-days’ to motivate staff, generate ideas and reflect and plan for both Service Users and the home generally. A family member of a resident at the home confirmed that she feels well informed and is able to give her opinion on matters concerning her relative. The Inspector examined the fire logbook and found that fire drills and checks are carried out at regular intervals. The home’s fire procedure is being revised by a member of staff, making it more specific to the home and generally more efficient. Records show that fire drills and checks are carried out at regular intervals. There are no recorded accidents since August 2004. Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 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 3 5 3 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 4 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 4 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 4 x 3 x x 3 x Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13.2 Timescale for action The registered person shall make 31/05/06 suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Holly Cottage DS0000066067.V288709.R01.S.doc Version 5.1 Page 26 - 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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