Inspection on 12/10/07 for Holly Cottage LLP

This inspection was carried out on 12th October 2007.

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

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

Other inspections for this house

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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 LLP 1 Egremont Street Ely Cambridgeshire CB6 1AE Lead Inspector Shirley Christopher Unannounced Inspection 12th October 2007 09:45 Holly Cottage LLP DS0000069959.V353346.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 Holly Cottage LLP DS0000069959.V353346.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. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Cottage LLP Address 1 Egremont Street Ely Cambridgeshire CB6 1AE 01353 661297 01353 661297 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) Holly Cottage LLP Mrs Vicki Amanda Berriman Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd May 2007 Brief Description of the Service: Holly Cottage is a family run business, which has been established for many years. Accommodation and staff support is provided for six residents with learning disabilities. The house is situated close to Ely city centre and full use is made of the local facilities. The home has its own transport and residents are encouraged to pursue a range of activities throughout the day and evening. Residents use to attend local day services, but day services have faced cuts so now Holly cottage provide their own day services from home. There is a designated room for activities, but most of the time residents are supported to access community facilities. There is a member of staff employed specifically to organise activities, but all staff are involved. The home is warm, comfortable and decorated to extremely high standards. It has six single bedrooms some are on the ground floor. The home has adequate bathroom facilities. The owners recently purchased a second property, which enabled them to extend the garden to Holly Cottage and to create an activities room. This is separate from the main living accommodation. The inspection report is available on request and the fees for the service are outlined. At the time of the last inspection they were £420.00 to £620.00 a week. Fees are being renegotiated because the home is now providing a day service. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, The Commission for Social care inspection carried out a key inspection to Holly cottage on the 12 October 2007. We arrived at 9.45 am. The home had an inspection in May of this year. Another inspection was necessary because the home changed its registration. The home had been operating as a care home for approximately 13 years with Mr Bent as registered provider. An application was received on the 30 March 2007 to change the registration from a sole provider to a Limited Liability Partnership (LLP.) This change of registration was approved in May 2007 and a new certificate issued. At the last inspection all the key standards were inspected and a report is available. It was noted as part of this inspection that very little has changed in such a short period of time. The report reflects this. For more information the reader should read previous reports. We during this inspection met some residents before they went off to do various activities. The manager, deputy manager, day care staff and care staff were spoken to. Some records were inspected including staff and residents records. The deputy manager completed an annual quality assurance assessment, (AQAA), which is a self- assessment tool prior to the inspection and some information from this has been included in this report. What the service does well: What has improved since the last inspection? The home is now providing day services from home and has done so after careful planning, consultation and consideration. The environment has been adapted for purpose and activities have been carefully chosen and will be evaluated. Risk assessments are in place for day activities. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holly Cottage LLP DS0000069959.V353346.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 Holly Cottage LLP DS0000069959.V353346.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 People who use this service experience good quality outcomes in this area. Residents needs continue to be meet by this home. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Residents have lived at Holly cottage for many years and moved there once an assessment of their needs had been completed. Their needs have been kept under review. The home has shown it can be flexible in meeting changing residents needs and external changes, such as the restructuring of day services. The Learning disability partnership (LDP) have been involved in meeting changing need. The statement of purpose has been updated to reflect the changes in the environment and the inclusion of day services. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use this service experience adequate quality outcomes in this area. The home responds to residents’ needs and meets their needs in an appropriate way. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: We looked at one care plan in detail. This had been reviewed every three months. When necessary the home should update plans more frequently when there is a clear change in need. Staff were clearly meeting residents’ needs but this was not always documented. This was evidenced through discussion. Staff were asked how they meet the residents’ needs. A lot of the things staff were doing were not written down, as part of the care plan. The home were audited by the contract and monitoring team earlier this year, (a report was available in draft.) One of the suggestions made was that the care plans should Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 10 be more person centred. The Learning disability partnership (LDP) have a facilitator who will work with the home to help them develop personal support plans. In order to do the facilitator will firstly spend time with residents and staff. They will be using a model called ‘my fantastic life.’ It was difficult to evaluate the existing care plans as the home were in the process of transferring much of the data. We observed residents being consulted about day-to-day decisions. The ethos of the home is very much about involving everyone in decision making. Examples include the sharing of the household chores; meal planning and deciding what activities and, or holidays should be taken. The home is nicely decorated and residents are consulted about colour schemes. We saw a number of risk assessments, which had just been completed and related to social activities. Staff are proactive in assessing and evaluating every new activity to see if it was successful and, or worth repeating. Risk assessments were also seen in relation to the environment, such as risk of scalding from radiators. No risk assessments were seen for activities of daily living, which may pose significant risk. This was discussed with the deputy manager. An example of this is residents may access the kitchen and assist with meals preparation/drinks. The deputy stated residents are supervised but this in itself is not enough. Staff must ensure they have assessed the risk and where necessary put a risk assessment in place to reduce or eliminate the risk. A requirement has been made in respect of this Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use this service experience excellent quality outcomes in this area. Residents engage in a wide range of purposeful activity, both in the home and in the wider community. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Residents were spoken to briefly as they were preparing for the day. There was a wide range of activities for residents to participate in through out the day. Residents had been consulted about what they would like to do and their individual interests considered. Residents are well established within the community and are always out in the evening and weekend, joining in any local events. This was evidenced through discussion and through records. The new space created for social activities is superb and overlooks the newly landscaped garden. This has different areas of interest. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 12 Photographs around the home depict group activities and the many holiday’s residents have had. Menus are on display and the cupboards and well stocked. Residents enjoy a well balanced diet. The deputy manager stated that links with family are maintained. Some residents have weekly contact. The home facilitate whenever possible to ensure residents see family members. The home celebrate all occasions, Christmas, birthdays and so forth and residents are encouraged to invite friends and family. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use this service experience good quality outcomes in this area. The home ensures residents’ needs are met and they access appropriate health care services. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: We spoke with a new member of staff who said that she had received a detailed induction, which included delivering appropriate personal care. Residents’ needs are documented in their care plans and staff spoken to showed a good understanding of these needs. Health care needs were documented but tended to be written in the daily notes and did not reflect the level of support needed and given by the care home and other health care services. Records pertaining to individual residents should be included in their own health record, and not on one record such as weight charts, which were all on one sheet for all the residents. If records are being Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 14 kept such as weight, they should be kept up to date. Access to health care services could be recorded on separate sheets under the specific headings such as GP visits. This would make information more accessible. We looked at one record and it looked like the resident had received no input from some services. This information would be written in the daily notes We inspected the medication only in relation to medication records and corresponding drugs on the day of inspection. The home has very little medication. There is a homely remedies policy, but residents are not routinely written up for drugs such as paracetemol. We had a discussion with the deputy manager about bereavement because this was significant for the person being case tracked. The home had been proactive in providing both emotional and practical support for the resident and had reflected on his or her own personal experiences. Other forms of support were not considered appropriate by the staff, but the staff may not always be the best resource for residents facing difficult issues. The home may wish to explore this further through advocacy services or specialist service provision. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use this service experience good quality outcomes in this area. The home has robust adult protection policies and procedures in place to ensure that residents are safe. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Holly cottage ensure that all staff receive training in the protection of vulnerable adults. There are adult protection policies and procedures in place and staff are made familiar with these as part of their induction. Staff are appointed subject to satisfactory references, criminal records check, (CRB) and satisfactory application form/and interview. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 16 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 People who use this service experience excellent quality outcomes in this area. Accommodation is of an extremely high standard and reflects the individual personalities and interests of the residents. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Holly cottage provides accommodation of an extremely high standard. It is warm, comfortable and decorated in bright colour schemes. The owners have devoted a lot of time in the property to ensure it meets the needs of the residents living there. They are consulted about any proposed changes to the home. The additional space for day care is a big advantage and creates a purpose built space away from the main communal area. There is also an enclosed garden, which is secure and nicely landscaped. There is a separate Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 17 shed. No maintenance issues were identified on the day of inspection and the home was spotlessly clean. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 18 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 People who use this service experience good quality outcomes in this area. Staff are given the appropriate support and training to assist them in meeting the requirements of the job. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: We meet a number of staff as they were going out for the morning with the residents to different activities. One member of staff remained in the home and was spoken to. Her file was inspected. The staffing rota was inspected. There are two staff on each shift, one sleep in and one on call. There is also a day care coordinator. We spoke to a staff member who confirmed that they had received an induction lasting several weeks. A senior member of staff shadowed them. They had completed all the mandatory training within the first six months of employment and had completed a learning disability qualification, (LDQ.) A Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 19 national vocational award, (NVQ) was the next step for them. They confirmed that they received regular supervision every six to eight weeks. They felt appropriately supported and said that there was good teamwork in the home. One staff file was inspected and had all the necessary pre requisite checks in place. At the time of inspection one member of staff had an NVQ qualification. Three staff members had just completed the course. New staff complete an LDQ. The deputy manager is an assessor for the course and there is an external verifier. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 20 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 People who use this service experience good quality outcomes in this area. The residents’ benefit from a well managed service, which puts residents first. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The manager and deputy manager work closely together. They share out the responsibilities for the on-call and the overall management tasks. Both have different areas of expertise. We asked the deputy manager about quality assurance and he confirmed that regular staff and resident meetings are held. There is also a newly devised Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 21 monthly task and check list. A quality assurance form is used for staff, residents and visitors. The form asks them for their views and comments about the home. Any concerns or suggestions for improvement would be responded to wherever possible straight away. The home does not have a written improvement, or business plan We checked a number of records and they were mostly satisfactory including: one resident and one staff file, finances and medication for the resident tracked. A number of maintenance records including fire and water temperatures, portable appliance testing and food records were inspected and were satisfactory. Risk assessments were in place for potential hazards in the home and these were satisfactory. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 22 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 3 X X 3 X Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(c) Requirement Risks assessments must be undertaken to identify all possible risks to residents. Timescale for action 30/11/07 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 Care plans should reflect the personal goals and aspirations of the individual. Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cambridgeshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Holly Cottage LLP DS0000069959.V353346.R01.S.doc Version 5.2 Page 25 - 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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