Inspection on 23/01/06 for Holly House And Oak Field

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly House And Oak Field 27/02/07

Holly House And Oak Field 05/07/05

Holly House And Oak Field 12/01/05

Holly House And Oak Field 24/09/04

Holly House And Oak Field 10/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Holly House And Oakfield 303 Gloucester Road Cheltenham Glos GL51 7AR Lead Inspector Peter Still Unannounced Inspection 23rd January 2006 14:15 Holly House And Oakfield DS0000016471.V281487.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 House And Oakfield DS0000016471.V281487.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 House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holly House And Oakfield Address 303 Gloucester Road Cheltenham Glos GL51 7AR 01242 522404 01242 522404 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) TRACS Miss Tanya Marie Walters Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (12), Mental Disorder, excluding learning disability or dementia - over 65 years of age (1), Physical disability (12), Physical disability over 65 years of age (1) Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the PD(E), MD(E), LD(E) Category refers to one named service user and will be removed when the service user leaves the home 5th July 2005 Date of last inspection Brief Description of the Service: Holly House and Oakfield is registered to provide care and accommodation for up to 12 people with a learning disability, physical disability and/or enduring mental health difficulties. It is run by TRACS; a specialist provider of care for people with acquired brain injuries and learning disabilities. The home is situated on the outskirts of Cheltenham. There are local facilities nearby including shops, a post office and a college of further education. The home has been adapted from two properties. There are 12 single rooms, three bathrooms, two lounges, a dining room and a kitchen. A conservatory is used as the designated smoking area. There is a large back garden with some outbuildings. The home has two vehicles. Residents also use taxis and buses. The home is close to the railway station. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours and the acting manager supported the inspection and was present throughout. Severn residents and five staff were spoken with and the files for two residents were specifically case tracked. There was one resident vacancy. A group discussion took place with residents as well as talking to four individual residents. One resident didn’t choose to speak with the inspector. A tour of the premises was completed and a range of files was reviewed. The acting manager had completed all the necessary documentation for his application to become the registered manager of the home and submitted it to the CSCI in October. He was awaiting a date for an interview with the Commission. What the service does well: What has improved since the last inspection? What they could do better: The provider must send a copy of the monthly, unannounced Regulation 26 visits to the home to CSCI. The last report sent to the Commission was dated 07/07/05 and the last report seen at the home was dated 29/11/05. Quality Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 6 assurance needs to be established, however work to support this had already started. 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 House And Oakfield DS0000016471.V281487.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 House And Oakfield DS0000016471.V281487.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 Residents benefit from good admission practice that ensures the home is suitable and can meet a persons needs EVIDENCE: Two files were reviewed as part of case tracking and both showed evidence of a comprehensive admission process. Careful planning and a visit with thorough assessment to the prospective residents own environment was seen. Trial visits had taken place and one resident talked very positively about the admission process and how the home had supported them. A comparison was also made by the resident concerning a previous placement, demonstrating happiness with the way their admission to Holly House had been arranged. Holly House And Oakfield DS0000016471.V281487.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, 8, 9 Residents had detailed care plans to support their needs. Care plans were well recorded but all care plans must be signed and dated. Consultation with residents ensures they can participate in all aspects of life at the home. Good recording of risk assessments ensures residents can be supported with an independent lifestyle but there must be regular review. EVIDENCE: Two care plans were used to case track the standards inspected. The care plans showed detailed care recording. The depth of care plans had improved since the last inspection, with goals and longer term needs identified. One main care plan file, held in the office had not been counter signed by the resident or dated and all files must be checked to ensure they are complete in this respect. A senior member of staff showed current care files to the inspector, which were held in a large locked cupboard in the dining room. Staff complete detailed daily recording, which provides information for the daily staff team and key worker to maintain the care plan. A form called ‘Preparing for Review’ was continuing to be valuable in drawing key information together and ensuring involvement of the resident. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 10 Regular client meetings were held each month and minutes were well recorded. A poster to remind residents about the meetings was seen, with an agenda. A member of staff runs the meetings and that member of staff also talks individually to each resident to ensure their views were heard. This was considered to be good practice, especially where one or two residents may be dominant to the detriment of others. It was clear that all residents were listened to and symbols were used to support communication. Risk assessments were recorded and specific evidence for one resident identified risks concerning a job and actions to reduce the risks. Risk assessments showed that residents were being supported to take risks as part of an independent lifestyle. However there was a lack of evidence of regular review, this was confirmed by a key worker. Holly House And Oakfield DS0000016471.V281487.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, 17 A wide range of social activity was available and enjoyed by residents. A healthy diet was provided. EVIDENCE: An enthusiastic staff team were working hard to ensure residents had choice and a wide range of social activity and six residents talked about enjoying the opportunities available. The home had increased the number of staff able to drive the home vehicle to nine and transport was an important aid to daily activity. Activity included: trips out in the home vehicle; occasional day trips out as a full group of residents in a large hire vehicle; Bristol Zoo; the local pub, where residents are known and there are good relationships; the cinema and the local Headway club. Resident’s had enjoyed holidays last year, and usually two residents would go together; a cottage in the Forest of Dean had worked well. A special trip to the Isle of Wight had also been enjoyed. Within the home, staff had an organised approach to activity, which was recorded. Staff take turns to provide activity sessions and on the day of inspection, residents were helping to prepare and decorate the home for the Chinese New Year. A new cookery workshop day had also been established, which provides both activity and guidance about healthy eating. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 12 Menu records were kept and showed a healthy and balanced diet. Fruit was available throughout the day. The inspector sampled the evening meal and would have wished to stay as suggested, since it was very tasty. Holly House And Oakfield DS0000016471.V281487.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, 20, 21 Resident’s needs were provided in the way they requested. Good recording ensured appropriate medication practice. Individual’s wishes were recorded. EVIDENCE: Six residents said that staff provided support in the way they wished and spoke highly of staff. In the office a visual forward planner with pockets for items such as appointment documentation, helped staff to remember key information. A file called ‘Read and Sign’ was also being well recorded so that staff communicated all key information to those arriving to work a duty shift. No resident was retaining their own medication and residents had signed and dated their consent regarding medication, which was held on their main care file. The care plan reviewed for one resident was seen to include details of last wishes, which had been discussed and recorded for the resident. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 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, 23 Resident’s views were listened to and steps were taken to address issues, though residents should be supported in making complaints, if they wish to. Staff must be provided with training concerning adult protection. EVIDENCE: Policy documentation regarding complaints had been re written since the last inspection and was clear and detailed. The client meetings and individual discussions with residents help to ensure resident’s views were listened to and acted upon. It was understood there had been no complaints since the last inspection, however there had been a matter of difficulty between two residents and a record of the matter was not seen. A recommendation will be made to discuss the way complaints and resident’s views are addressed. Residents need help to understand that making a complaint can be positive and help the home to improve and address issues of concern. Details about how to make a complaint and forms for residents to use were available in the dining room. Staff must have training so they can be confident in their understanding of abuse: the signs of abuse; the different types of abuse; ‘No Secrets’ and of the steps to take if they have a concern that there may be abuse. It was understood that the training had been agreed and that it would be provided soon. Reinforcement of this training is important and should be built into staff training programmes and new staff would require it as part of induction. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 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, 30 The property provides space and comfort for residents and the environment was generally in good order. A water pressure problem must be investigated and resolved. EVIDENCE: At the last inspection the outside area, especially to the front was very overgrown. It this inspection is was noted that a lot of work had taken place and the garden was looking very well indeed, especially for the time of year. The exterior of the property had been newly painted. At the last inspection, there was concern about the conservatory, used for residents to smoke in. The Fire officer had been contacted and was content with the means of escape from the conservatory, which continued to have a chain and padlock hidden by cloth to keep doors into the garden locked. The manager was concerned about the look of the locking system and there are plans to resolve it. The conservatory was badly stained with cigarette smoke and there were plans to provide a weekly clean. A ground floor bedroom where there had been a damp problem had a new ceiling and the problem resolved. A first floor bedroom doorframe had been damaged by a resident and was undergoing significant works. The dining room Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 16 floor was in need of replacement due to wear and the kitchen floor should be on a programme for replacement. One resident showed the inspector a problem with water pressure, creating a slow water flow and this must be investigated and resolved. This type of issue was an example of a matter, which may be recorded as a complaint and it had not been, even though the resident had raised the issue. The records for the weekly tests of emergency systems were inspected and found to be up to date. The home was warm, clean and tidy. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 17 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, 36 Residents benefit from a qualified and enthusiastic staff team who feel supported and work well together. EVIDENCE: The standard concerning staff training to NVQ Level 2 or above had been exceeded. The position was as follows: twelve staff had gained NVQ level 2 out of a staff team of 15. The acting manager will complete his registered managers award by June 2006 and was working to completion of his NVQ Level 4 by December 2006. A staff training matrix showed evidence of staff training and was a valuable management tool. Three staff were specifically interviewed during the inspection. A number of staff changed due to their work shift and it was particularly noticeable that every member of staff was seen to be confident and smiling. One member of staff said, “ I love my job, I think the home now has a very good team and if I have a problem, I have people around me to provided support. I think the support from other staff and the manager is fantastic”. Residents spoken with were clear about the positive way staff support them and gave good praise. The remarks above were similar to many others made by other staff. The staff team and their manager should be congratulated for the way they have developed their team and for the positive way they present themselves. Staff found that supervision, which was on an eight weekly basis, was consistent and helpful. Staff felt valued and when they had innovative ideas, Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 18 were listened to, with good ideas being promoted. Staff also felt that the key individual responsibilities they had were important to the successful running of the home. Two staff files were read and showed good recruitment practice. Concerning staff recruitment, the home currently had the equivalent of one and a half full time posts vacant. A decision was taken to attend a two-day Jobs fair to help in seeking new staff that would compliment the staff team and this had proved valuable. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 19 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): 38, 39, 42 Resident’s benefit from effective leadership. Once implemented, a selfauditing tool will help to ensure resident’s views underpin self-monitoring and home review. The provider must send regulation 26 visit reports to the CSCI. Management practice helps to ensure residents are kept safe. EVIDENCE: The acting manager had worked hard to develop the ethos of the home and his leadership was seen to have a positive effect. Residents spoken with said they felt safe and that they could go to staff if they had concerns. The management of the home will be helped when a computer can be made available to the home. This would mean that such things as care plans and risk assessments could be brought up to date without any delay. The manager said he was keen to develop practice and this was considered to be positive and an indication that the manager feels there is always room for improvement. He promotes an ethos of staff owning the policies and working practice of the home and for each member of staff to have their own key role. The manager was supernumerary to the staff team and works some evenings and weekends to ensure he can support and manage the work of his staff. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 20 The provider had not been sending a copy the regulation 26 visits of the home to the CSCI and must do so. The last report at the CSCI office was dated 07/07/05 and the report reviewed at the home was dated 29/11/05. The visits must be unannounced and on a monthly basis. The provider had given a self-auditing tool for the home to use, it was comprehensive and should be helpful with quality assurance and the home had set a deadline for completion by the end of February 2006. The home sets an annual goal and there were plans to meet with residents in March to work on it. A staff quality questionnaire had been completed but no other surveys for residents or other people significant to the residents had been undertaken. The provider company is responsible for a number of homes and runs a focus group for their homes, where time is set aside for each home to voice specific issues and improvements for their service. Whilst more work is needed, it is clear that many steps had already been taken or are about to be to comply with this standard. A senior member of staff holds a remit for Health & Safety to support the manager’s responsibility with this task. The member of staff showed confidence in the role and was able to provided records of evidence for inspection. The standard appeared to be satisfactory, with points of concern being noted. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 21 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 3 2 X LIFESTYLES Standard No Score 11 X 12 4 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 X 2 2 X X 3 X Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 22 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 2 3 4 5 6 Standard YA9 YA23 YA24 YA43 YA39 YA41 Regulation 15(2)(b) 13(6) 23(2)(j) 26 24 17 Requirement Ensure all risk assessments for residents are reviewed on a regular basis. Provide staff with training about the protection of vulnerable adults. Investigate the slow flow of water identified by a resident and resolve the problem. The provider to send a copy of their monthly visit report to CSCI. Develop and implement the quality assurance systems for the home. Check all care plans to ensure they have all been signed and dated. Timescale for action 31/03/06 30/06/06 17/03/06 31/03/06 31/08/06 31/03/06 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 YA24 Good Practice Recommendations Replace dining room floor covering and consider kitchen DS0000016471.V281487.R01.S.doc Version 5.1 Page 23 Holly House And Oakfield 2 YA22 floor replacement. Support staff and residents to have greater clarity about making a complaint so residents are encouraged to do so when they wish. Holly House And Oakfield DS0000016471.V281487.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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