Inspection on 22/06/05 for Holly Dyke

This inspection was carried out on 22nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 15/08/06

Holly Dyke 18/11/05

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 Workington Cumbria CA14 3RP Lead Inspector Cath Wilson Announced 22 June 2005 10:30 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 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 Stationary 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 F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holly Dyke Address 19 Crummock Road Workington Cumbria CA14 3RP 01900 606170 Telephone number Fax number Email 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 Care Home 6 Category(ies) of LD - Learning Disability registration, with number of places Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29 November 2004 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, that 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. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that started at 10.30am and took place over 5 hours during the day. Family members provided valuable views to the inspector prior to the inspection using the Commission for Social Care Inspection comment cards. People were met in the home during the inspection, as were the manager and staff. A number of records were assessed and the premises both inside and out were looked around. What the service does well: What has improved since the last inspection? What they could do better: Ensure that the monitoring of staff availability continues to be monitored and the appointed senior post is taken up sooner rather than later. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 6 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 F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4 and 5 The admission procedures ensure that prospective residents receive the information and support they need to make an informed choice before moving into the home. EVIDENCE: The admission procedure is kept up-to-date and guides the manager and staff on the important actions to take in assessing and planning for an individual entering the home. This process includes gaining the views of others in the home to ensure any new person to the home can be made as comfortable as possible. The newly appointed manager and staff are well informed of people’s needs and wishes and place great importance on people’s continued health and welfare. A Statement of Purpose and Service User Guide are provided and in a format that is both informative and accessible. These documents are currently under review to make sure they accurately reflect the home’s purpose. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 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 standard(s) 6, 7, 8, 9 and 10 The systems in place for resident consultation is very good with a variety of evidence available that indicates people’s views are both sought and acted upon. People involve themselves in all aspects of their lives in either an individual or communal way. EVIDENCE: People are very involved in the way their care and support is provided and this is detailed in their individual care records. These are kept up-to-date so that the manager and staff are appropriately informed of people’s needs and wishes. People are comfortable and at ease in their surroundings and supported in their personal choices by an experienced and knowledgeable staff group. Risk assessments are kept up-to-date to enable people to live their daily lives in a safe and measured way. People are supported to have a real ‘voice’ in the way they live their lives and are supported to attend people forums both locally and nationally. The home involves specialist assistance in their ongoing assessments of people’s needs. Confidential matters both spoken and written are appropriately dealt with. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 10 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 standard(s) 11, 12, 13, 14, 16 and 17 Social activities and meals are both well managed, include personal choices and provide daily variation and interest for people living in the home. EVIDENCE: People are provided with appropriate personal care and support in a manner that maintains their dignity. Throughout the inspection residents were supported to attend their chosen leisure, educational and social interests in both the home and the community. Arrangements were in place for contact to be maintained with family and friends. People’s individual preferences are detailed in their records. Personal choices, likes and dislikes are catered for and meal times whether these be in the home or on visits to local cafes and restaurants respected. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 11 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 standard(s) 18, 19, 20. People’s individual health, personal and social needs are recorded in an accessible and detailed manner. The manager and staff have detailed knowledge of people’s comprehensive needs and requirements through the care planning used. This greatly limits any possible or potential risk to people in the home. EVIDENCE: People have an individual and personalised care plan that comprehensively details their needs and the actions taken to meet them. These documents are up-to-date and monitored by the manager and senior staff on a regular basis. People are enabled to air their views about how they live their lives to the manager and staff and were seen to do so. Important events in the home and daily records are recorded, as are personal and environment risk assessments. Medication is securely stored and administered and staff are following the home’s policy and procedure for this. Designated staff had been trained in this system. The manner in which people’s health and personal care is provided by the manager and staff shows that at the time of this announced inspection people are protected and safeguarded. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 12 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 standard(s) 22 and 23 The arrangements for complaints management, vulnerable adult procedures and seeking the views of people in the home are handled very well and ensure that people feel listened to and protected EVIDENCE: The home is currently updating the complaints and response recording system to ensure outcomes are recorded in a more easily monitored way. People in the home are aware of how to complain and are listened and responded to. People in the home and the manager and staff meet regularly to discuss matters either together or individually. The manager and staff are fully aware of adult protection procedures and the practices needed to safeguard people in the home. On-going arrangements for updating staff training in these matters will ensure the continued protection of people. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 13 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 standard(s) 24, 25, 26, 27, 28, 29 and 30. People are provided with a bright, comfortable and safe environment. EVIDENCE: The home provides a comfortable and homely place that is well maintained and clean. A recorded programme is in place to maintain the furnishings and fittings in both the private and communal rooms. The manager and staff are currently assessing the arrangements for bathroom facilities so that service users can fully benefit from a specialist bath they feel comfortable using. People’s bedrooms are arranged in the way they want them and the manager and staff support them in doing this. Each room is individual and privacy locks are used. The outside garden and patio areas have been attended to and provide a pleasant and relaxing area. The last visit from the Development and Environment Office and Fire Safety Officer were satisfactory. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 The home follows the Walsingham procedures for the recruitment of staff. These are robust and offer protection to people living in the home as does the training and development programme for all staff. EVIDENCE: Staff are very committed to providing very positive life experiences for people in the home. They are provided with a very well organised training programme that takes into account the overall needs of people in the home. Staff are provided with regular supervision so that their ongoing work is focussed on meeting people’s many needs. There is a programme for in-house training as well as a high percentage of staff with NVQ qualifications. Staff feel very supported in their work. Staff provide a consistent and satisfactory service and often do additional shifts to maintain this. The manager monitors staffing availability. A recent appointment of assistant manager will greatly benefit staffing numbers. This position has not yet been taken up due to allocation of work elsewhere. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 and 43 The recently appointed manager has a very positive vision and commitment to make sure that residents receive an appropriately consistent quality of care. This will promote and safeguard the health, safety and welfare of people in the home. EVIDENCE: The manager and staff are clear about their roles and balance their work so that individual and communal needs of people in the home are met. Prior to her appointment the manager had previous experience in this home and is very conversant with the comprehensive needs of the people who live here. The manager’s application to be the Registered Manager of the home is currently being processed by the Commission for Social Care Inspection The records assessed during the inspection ensure that people’s rights and best interests are safeguarded. Individual records for people are comprehensive, well written and up-to-date and set out the clear actions and progress being Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 16 made. Records indicated that fire drills and instructions had taken place regularly. Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 4 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Dyke Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 18 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 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 Good Practice Recommendations Holly Dyke F58 F10 s22677 holly dyke v210092 220605 ai stage 4.doc Version 1.30 Page 19 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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