Inspection on 15/08/06 for Holly Dyke

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Holly Dyke 18/11/05

Holly Dyke 22/06/05

Holly Dyke 29/11/04

Holly Dyke 14/07/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Holly Dyke 19 Crummock Road Workingon Cumbria CA14 3RP Lead Inspector Cath Wilson Unannounced Inspection 15 and 16 August 2006 10:00 th th Holly Dyke DS0000022677.V300716.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 Dyke DS0000022677.V300716.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 Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Dyke Address 19 Crummock Road Workingon Cumbria CA14 3RP 01900 606170 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) Walsingham Ms Sarah Elizabeth Ritson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 18th November 2005 Date of last inspection Brief Description of the Service: Walsingham provides the services and care at Holly Dyke for six people who have a learning disability. The home is a detached dormer bungalow on the outskirts of Workington and blends in with other houses in the area. Car parking facilities are to the side of the home and there is a large enclosed garden area to the rear. There are six single occupancy bedrooms in the home and two of these are on the ground floor. The lounge and dining room, can be partitioned, kitchen and utility room are on the ground floor. The office is situated on the first floor and bathroom and toilet facilities are on both floors. The current scale of charges is £1255.19p to £1267.54p. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to Holly Dyke that took place over a two-day period. During this time all the key standards of the National Minimum Standards were assessed. The first visit to the home was over a short period in the morning. The second visit included the afternoon period. During both visits to the home I was able to meet residents and meet and talk with staff. A tour of the premises both inside and out was undertaken. Staff, resident’s records and administration files were assessed. The registered manager had completed a pre-inspection questionnaire prior to this visit. This assisted in verifying information throughout the inspection. What the service does well: What has improved since the last inspection? There is very clear evidence that the manager and her staff continue to provide and improve the services and care provided in a very proactive and inclusive manner. The provision of new and specialised bathing facilities is a great improvement and service users greatly approve and appreciate this. Holly Dyke DS0000022677.V300716.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. Holly Dyke DS0000022677.V300716.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 Dyke DS0000022677.V300716.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area was good. This judgment has been made using available evidence, including a visit to the home, meeting the manager and staff and viewing related documentation and records. The home has good procedures and documentation in place to ensure appropriate referrals and they admit people to the home whose needs they can meet. EVIDENCE: There is a Statement of Purpose and Service User Guide available as well as other information about the home’s provision of services and care. These documents are progressively reviewed and updated and are in a format that is accessible. Prospective service users can visit the home prior to admission to the home, as can relatives and or representatives, allowing people the opportunity to make an informed decision. Part of this process is to take into account the needs of people already living in the home. Comprehensive assessments are undertaken for service users. This information is used to make sure people’s care needs are clearly identified and informs the care planning system used in the home. Each resident has an individual contract of terms and conditions of residency. These are currently being reviewed to ensure that all contracts are appropriately signed. Holly Dyke DS0000022677.V300716.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service, assessing care documents and discussions with service users, staff and senior managers. People had been provided with the care they required in a caring and dignified manner and their care needs recorded. EVIDENCE: There are individual care plans for people and much work and attention has been undertaken on these. This continues and the manager and staff are looking at ways to further strengthen the records to show the achievements of outcomes for people. There was also evidence to clearly indicate that staff are constantly seeking ways to further enhance people’s lives through better communication, enlisting other professional personnel for advice and training. This is very good practice. The manager and staff are very well informed of people’s needs and these include their cultural and religious preferences. The care records are kept up-to-date and are informed by the use of daily records and regular staff meetings. People’s personal information is confidentially stored. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 10 Risk assessments and management strategies are in place and work continues to integrate these more into the care planning system. Holly Dyke DS0000022677.V300716.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. People’s rights are very much promoted and their individuality respected. Mealtimes are catered for on an individual basis taking choice and balance into account. EVIDENCE: People’s leisure and community involvement is detailed in their records and staff supported people to attend these. These include people’s cultural and personal beliefs. This had been achieved in a manner that respected people’s individuality and wishes. Staff who met with me displayed a great interest and enthusiasm in encouraging people to have meaningful and enjoyable experiences. Seeking opportunities to further people’s choice and participation in everyday events. Family members are encouraged to have and maintain contact. Mealtimes are arranged to meet individual need that includes a healthy balance. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using evidence including a visit to the home, assessing documentation and medicines arrangements and talking with staff. Health care matters are well managed and documented but a review of the recorded detail would ensure that appointment outcomes are recorded consistently. EVIDENCE: Staff are very knowledgeable of peoples needs including their health care arrangements. The staff team work very positively with the local health care professionals to offer a responsive and supportive approach in assisting people to maintain and receive the right attention. Specialist assistance and guidance is incorporated into the home’s approach and practices and actions regularly reviewed. Training has been provided to staff regarding medicines management in the home. The records assessed at this inspection were generally very good but there was an inconsistency in the ongoing provision of dental appointments not being provided. The home is following this up to ensure appropriate dental care is regularly provided. Policies and procedures for medicines handling are in place and are appropriate for the home. Records indicated however, that there is much work being achieved in supporting Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 13 people in their health care needs and individuality is sensitively attended to ensure people’s dignity is upheld. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home’s system for managing service user’s finances is sound. The home’s complaints system is available to both service users and their family and arrangements for vulnerable adult procedures are well managed. EVIDENCE: There is a complaints procedure in place and service users and staff fully informed of this. Adult protection matters are an integral part of the staff training programme and arrangements in place to keep up to date with this. There have been co complaints made about the services and care at Holly Dyke since the previous inspection. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 15 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, 25, 26, 27, 28, 29 and 30 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this home and meeting with service users and staff. People benefit from living in a comfortable environment that is well maintained and safe. EVIDENCE: Arrangements are in place for the health and safety of people in the home and for their environment. Guidelines are followed and records are kept up-to-date regarding environmental health and fire safety. Specialist equipment is regularly serviced and the home had access to advice and guidance regarding environmental matters. Each resident has their own bedroom and arrangements are in place to upgrade and replace furnishings and décor when needed. People in the home and staff work together to provide a very comfortable, pleasant and well-maintained environment and one they feel very proud of. Current discussions include arrangements for the hallway décor. The provision of a new and specialised bath has pleased people very much and who think this facility is ‘great’. The outside garden area is also very well maintained. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 16 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, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service, meeting residents and staff and assessing documentation. Staff are very motivated and committed to meeting the comprehensive needs of people in the home. EVIDENCE: Staff are provided with a good training and development programme and the manager and senior staff are pursuing additional training issues so that they can enhance the lives of people in the home. There is a high percentage of staff that has NVQ qualifications. The staff I met during the inspection are well informed of the needs of people and certainly have great commitment to placing their needs first and provide them with life enhancing experiences. New staff to the home had had a clear induction period into the home and they are appropriately supervised during this. Their training needs are identified and they are supported and encouraged in their work. There was an enthusiasm present in this staff group that is encouraging and they showed imaginative ways to further include service users in the decision making process. Looking at ways to make information user-friendly and more accessible is an ongoing process for them but these are all examples of good care practices. The home follows the recruitment procedures of Walsingham. Staff had all the appropriate checks and references completed prior to taking up their post and all appointments are subject to a probationary period. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home, meeting service users, senior staff and care staff and assessing the home records and documentation. People benefit from a service that places their personal need first and where they are valued as individuals. EVIDENCE: There are good systems in place that attend to and support the comprehensive needs of service users. Staff are very focussed on meeting the needs of people and to seeking ways to enhance their lives. Walsingham monitor the delivery of services and care and their operations manager carries out quality assurance checks on regular unannounced visits to the home. The Commission for Social Care Inspection is notified of the outcome of these visits. The registered manager also informs the Commission for Social Care Inspection of important events that happen in the home. The home are developing and strengthening their methods of Quality Assurance. General Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 18 health and safety matters are attended to. The records examined on the day of the inspection were well ordered and confidentially stored. Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 4 4 3 3 X Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 20 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. Refer to Standard Good Practice Recommendations Holly Dyke DS0000022677.V300716.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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. 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