Inspection on 20/02/07 for Holly Tree Cottage

This inspection was carried out on 20th February 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Tree Cottage 18/10/07

Holly Tree Cottage 08/11/05

Holly Tree Cottage 26/05/05

Holly Tree Cottage 12/10/04

Holly Tree Cottage 04/06/04

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 Tree Cottage 243 Berrow Road Berrow Burnham-on-Sea Somerset TA8 2JQ Lead Inspector David Kidner Unannounced Inspection 20th February 2007 09:30 Holly Tree Cottage DS0000058862.V325159.R02.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 Tree Cottage DS0000058862.V325159.R02.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 Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Cottage Address 243 Berrow Road Berrow Burnham-on-Sea Somerset TA8 2JQ 01278 788008 01278 787939 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) www.homes-caring-for-autism.co.uk Somerset HCA Ltd Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Upstairs bedrooms must only be used for service users who are physically mobile. 8th November 2005 Date of last inspection Brief Description of the Service: Holly Tree Cottage is registered with the Commission for Social Care Inspection to provide care and support for up to seven people who have a learning disability. The house is a large detached property set close to public transport links and within walking distance of a shop and public house. All bedrooms are for single occupancy and three bedrooms have full en-suite facilities. The home has two communal bathrooms located on the first and second floors. Communal areas are located on the ground floor; these consist of a dining room, a lounge and conservatory area. There is a domestic style laundry facility. To the rear of the property is a large garden. The home is owned by Somerset HCA Ltd. There is a vacancy for the post of Registered Manager. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a Key Unannounced Inspection and was conducted by one Inspector. The inspection lasted one day (8.0hrs). The Inspector met most service users and a number of the care team. The Manager was available throughout the inspection. The Area Manager was present for some part of the inspection and was also present at feedback. As part of the inspection process the inspector viewed records in relation to care and support plans, health and safety, medicines, risk management, the management of behaviours and physical intervention, staff recruitment and viewed all areas of the home. The Inspector spoke to some service users in private and in communal areas and spoke to a total of four care staff. The Inspector would like to thank the service users for making the Inspectors welcome in their home and for their contribution in the inspection process. The Manager and care team were very welcoming. As part of the inspection process the Inspectors sent comment cards to all service users. All the questionnaires were returned. Comment cards were sent to six relatives. All were returned. The Inspector sent comment cards to all care managers; four were returned. It was very pleasing to have so many replies. On the whole the comments were extremely positive in relation to the care and support provided at Holly Tree Cottage. Service users are very happy with the services that they receive. There is much evidence that service users are fully involved in decision making and access many community facilities. All service users spoken with stated that they are happy living at the home and that the staff treat them with respect. Relatives commented that the care team are patient, welcoming and understanding. Some relatives commented that communication could be improved. Activities are age appropriate and the home delivers an exceptionally high standard of care. On the whole care managers were also complimentary of the services but also highlighted matters relating to communication and staffing levels. As a result of this inspection the home has three requirements and ten recommendations. What the service does well: Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 6 The home supports people with complex needs and strives to promote independence, empowerment and decision-making. Throughout the inspection the Inspector noted that there was constant interaction between the care team and service users. The Inspector noted that staff were offering service users choices in all aspects of day-to-day living. All service users have a full activity programme, which includes leisure and educational elements. There are many opportunities for service users to access community based leisure and educational facilities. Staff work flexibly to enable service users to attend events during the day and evening. Holly Tree Cottage provides a comfortable home for service users. Bedrooms reflect individual needs and preferences. The home is clean and well maintained. Staff appeared extremely well motivated and confident in their roles. The home is pro-active in promoting a well-trained workforce. Over 50 of the care team have obtained NVQ Level2 or above. Service users spoken to stated that Holly Tree Cottage was ‘their home.’ All appeared comfortable to access all communal areas or spend time in the privacy of their rooms. What has improved since the last inspection? What they could do better: Wherever possible service users should be involved in the development of their care plan and sign their agreement. Risk assessments should be conducted in relation to service users being involved in activities that further promote independence and if restrictions are imposed. The home uses a ‘reward system’ as part of the process used to address the management of behaviours. Each service user has an individual reward that they have chosen which will be delivered if certain goals areas. It is recommended that the use of this system be detailed in individual service users care and support plan and that this is regularly reviewed. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 7 The Manager should countersign records of accidents and incidents. The home should give consideration to ways in which communication with relatives could be further improved. All staff must be provided with training on safeguarding adults. 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 Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 8 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 Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 9 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): 1 Key Standard 2 was not assessed at this inspection, as there have been no admissions since July 2005. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Holly Tree Cottage has a detailed Statement of Purpose and Service User Guide. EVIDENCE: The Statement of Purpose and Service User Guide reflect the services offered in the home. The Statement of Purpose was updated in February 2207. The service has now appointed a Director of People and Culture to their Board. This role will also include assisting the organisation to develop the service that is offered to service users with autism, staff training and development and to working collaboratively with the Purchasers of services. The fees charged vary according to the individual’s assessed need. Currently fees range from £1250 to £2198 per week. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care Plans are detailed and regularly reviewed. Service users are able to make choices about all aspects of their day-to-day lives. Risk assessments have been developed and reviewed regularly but further risk assessments are needed to promote independent living skills and restrictions imposed (if any). EVIDENCE: The Inspector viewed three care and support plans. It was noted that the care and support plans had recently been reviewed/updated. However, they had not been signed to confirm the agreed plan of care and they did not demonstrate that service users had been involved in the development of their personal care and support plan. It is recommended that wherever possible service users are Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 11 involved in the development of their care plan and sign their agreement. The manner in which they are presented is in the process of being reviewed to ensure that they are more user friendly. The care team complete a daily diary for each service user that records the activities and care and support provided on a day-to-day basis. This is kept in the form of a monthly document. The care team also complete monthly summaries. The home uses a ‘reward system’ as part of the process used to address the management of behaviours. Each service user has an individual reward that they have chosen which will be delivered if certain goals are achieved. The explanation and the use of each individual’s reward are detailed with targets set. At the last inspection it was recommended that the use of this system be detailed in individual service users care and support plan and be regularly reviewed. This has not been implemented and remains a strong recommendation. The Inspector spoke to five of the service users both in private and in small group settings. Service users confirmed that they are offered choices in all aspects of daily living. Prior to the inspection the Inspector sent comment cards to all service users at Holly Tree Cottage. The comments received also confirmed this. On the day of the inspection it was noted that staff were offering service users choices in food, drinks and activities. Presently, none of the service users are fully able to manage their finances. The relatives of six service users are appointees. However, the home has set up a system for one service user to independently ‘part manage’ their finances. Records are kept of all transactions. The home has conducted a number of individual risk assessments to address the management of behaviours, safety and promoting independence. However, it was noted that not all service users had risk assessments completed for some independent living skills restrictions imposed, such as accessing the kitchen without support. The Manager must ensure that risk assessments are completed where restrictions are imposed and to further promote independent living skills. At the time of the inspection the Inspector was advised that the format of the risk assessments would be reviewed. However, the risk assessments viewed had all been recently reviewed and dated. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 12 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 14 15 16 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Holly Tree Cottage offers the service users many opportunities to access community based facilities. Contact with families is encouraged and promoted. The home involves the service users in the development of menus and strives to promote healthy eating. EVIDENCE: A number of service users access the local college and partake in courses such as pottery and woodwork. The Manager advised that the home is actively seeking work placement/experience for some service users. At the time of the inspection the manager received a phone call advising that a possible work experience placement may have been found for one service user. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 13 The service users are fully involved in identifying the activities that they wish to access. Each week the service users choose what activities that they wish to pursue that week and this is then recorded on individual activity planners. Some of the service users that the inspector spoke to showed the Inspector their activity planner. Activities included swimming, sports centre, walks, bowling, listening to music and watching DVD, The Lynx Centre and going to the pub. The home conducted a service user questionnaire in November 06 that requested feedback on the activities that they do in and out of the house. All responses were very positive. The service users said that they were very happy with the activities but on occasions activities may not happen if staff are on sick leave. As part of the inspection process the Inspector sent comment cards to service users relatives. All comment cards were returned. The vast majority of the comments received were very positive about the services offered at Holly Tree Cottage. Comments included “ a friendly and very well managed home” “ cheerful and friendly staff” “family atmosphere”. The Inspector received mixed comments from relatives in relation to communication. Some relatives felt that communication was excellent; some thought it could be improved. This was discussed with the Manager and Area Manager at the time of the Inspection. It is recommended that the home consider ways in which communication with relatives could be improved. Service users keep in touch with family and friends by telephone and regular visits home. The home has a portable phone that service users can use if they do not possess a personal mobile phone. All post is delivered to service users unopened and staff offer assistance with correspondence if requested. All service users are offered the use of a key to their bedroom. Some service users stated that they have a key but choose not to lock their bedroom door. The care staff and the service users cook all meals. There is a four-week menu that gives a wide variety of meals. The service users are involved in the development of the menus and assist in the house shopping. Service users stated that they are able to have an alternative at any mealtime. At the time of the inspection one service user was being supported by the care staff to prepare the evening meal. All service users who expressed an opinion stated that the quality of food in the home was very good. Some staff felt that they would like to receive further guidance and confirmation that the meals that are prepared are healthy and nutritious as they wish to provide a healthy, well balanced diet. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 14 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 Quality in this outcome area good This judgement has been made using available evidence including a visit to this service. Privacy and dignity is promoted in the home. Service users have access to a variety of healthcare professionals. Medicines are well managed. EVIDENCE: Some service users have their own en suite facilities and there is a communal bathroom on each floor. Care plans give details of the level of assistance required with personal care. Service users that the Inspector spoke to stated that there are no set times for getting up or going to bed. The care staff that the Inspector spoke to demonstrated how the home promotes privacy and dignity. Service users stated that staff always knock bedroom doors. Wherever needed, service users have access to speech and language therapist and physiotherapist. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 15 All service users are registered with a GP and access services from other healthcare professionals as and when needed. The Inspector viewed documentation in relation to service users accessing Consultants at Out-patient appointments and being supported when being an In-patient at General Hospitals. One service user stated that the care staff supported them when in hospital following surgery. Care staff were present as a friendly and familiar face. The Inspector viewed the Medication Administration Record sheets (MAR) and found them to be correctly signed when administered or refused. Some medication is given on a PRN (as required) basis and the home has now developed guidelines for the use of such medicines. The home does not keep homely remedies. At present painkillers are individually prescribed. The Manager will be looking at making homely remedies available for individual service users as needed following consultation with the GP. The Manager is aware that a Homely Remedies Policy will be needed. All service users have a lockable cupboard in their room where medication is stored and dispensed from. Currently no one living at the home administers their own medication. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has policies and procedures to protect vulnerable people although some improvements could be made to make them more robust. All staff must be provided with training on safeguarding adults. EVIDENCE: The home has policies and procedures in respect of making a complaint, recognising and reporting abuse and whistle blowing. The Complaints procedure is located in the homes statement of purpose and service user guide. The Pre-Inspection questionnaire stated that the home has received three formal complaints. When viewing the Complaints record it was noted that there was only one entry. The Manager was not able to comment upon this due to only being in post for a short period of time. However, the Manager stated that this would be further investigated. Staff spoken to were aware of the whistleblowing policy and demonstrated the action that they would take. Service users stated that if they were unhappy with any aspect of their care they would approach a member of staff, their relative, care manager or the CSCI. The Inspector noted from the service user meetings that service users are regularly informed of how to make a complaint Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 17 and if there were any issues that they would like to raise. The vast majority of relatives stated that they knew how to make a complaint. The Area Manager stated that they would ensure that all relatives were familiar with the complaints process. Staff training records indicated that only two staff had received training on safeguarding adults. For the protection of vulnerable service users, all staff must be provided with this training. As previously stated the home uses a reward system in relation to the management of behaviours. The home has trained most staff in the use of positive response training (PRT). Records are kept of all incidents and where physical intervention has been used this has been recorded. The Inspector recommends that the Manager countersign all incident records as part of the audit process. This will enable the Manager to monitor the number of incidents that may necessitate the use of PRT. The Inspector was advised that the relatives of six of the service users are their appointees. The home supports service users to access their finances. All service users have an individual bank/building society account. Records are kept of all financial transaction. The Inspector sampled some records, balances were correct and receipts had been obtained wherever possible. Records had been signed by two care staff and wherever possible, by the service user. However, the Inspector advised that as part of the audit process the Manager should regularly check individual service user bank statements to ensure that they reflect the withdrawals and deposits made. This was agreed. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 18 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 25 26 27 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Holly Tree Cottage provides a comfortable home for service users. Bedrooms reflect individual needs and preferences. The home is clean and well maintained. EVIDENCE: The Inspector viewed most areas of the home. They appeared safe and comfortable. The premises are accessible to all the service users. There is a communal lounge with a conservatory off of this area and a large dining room. The service users and care staff advised the Inspector that the lounge area is to be redecorated in the near future. Service users have been involved in choosing the colour of paint. There was evidence of this as there was of paint samples on the walls, which the service users discussed with the Inspector. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 19 The dining room has specialist seating. The Inspector had discussions with the Manager and Area Manager as to the need for such specialist furniture as this detracts from making this a homely and domestic style dining area. It was agreed that this would be given further consideration. The Inspector was advised that there are plans for some major refurbishment of pipe work and other mechanical services at the home. CCTV is installed at the home but this is restricted to entrance areas for security purposes. Three service users showed the Inspector their bedroom. All bedrooms reflected individual needs, lifestyles and preferences and contained many personal possessions. The service users stated that they are very happy with their bedrooms. One bedroom is currently being investigated for an area of dampness. Three bedrooms have full en-suite facilities. There are two communal bathrooms on each floor. There are adequate toilet facilities. The home has appropriate hand washing and hand drying facilities. The home has a domestic style laundry. All cleaning chemicals are stored securely. The laundry room appeared well managed. On the day of the inspection the home was clean, hygienic and free from offensive odours. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 20 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 33 34 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home promotes staff to obtain formal qualifications. The Manager ensures whenever possible that there are sufficient staff on duty to enable service users to participate in social and leisure activities. Staff are provided with regular opportunities to attend training. The home must ensure that staff recruitment records contain all relevant documentation. EVIDENCE: The home employs sixteen care staff. A total of nine care staff have obtained NVQ Level 2 qualification or above this equates to 56 of the care team and therefore meets the standard of 50 of the workforce to have obtained this qualification. The majority of staff have undertaken training in autism awareness, epilepsy, communication and picture exchange communication system (PECS). All staff have received positive response training (PRT). Some Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 21 staff have received training in Somerset Total Communication (STC). The Manager has identified the care staff that need to undertake such training. The Manager stated that at present there are usually five/six care staff on duty during the day. There is a one waking and one sleep in person during the night. Rotas are adjusted to meet the specific needs of service users. The service users lead a very active life and this is commended. The Inspector received some comments from some service users, care staff and relatives that on occasions activities/events are cancelled due to staffing shortages. This is usually due to staff sickness and annual leave. Staff will usually provide cover at short notice to avoid service user’s disappointment if activities are cancelled, but this is not always possible. The Manager has advised that the provider is in the process of creating a ‘Flex team’ of staff that will be available to all homes, so that appropriate staffing levels may be maintained at all times. The Inspector viewed the recruitment files of three recently appointed staff. The files did not contain all the required documentation as required by Schedule2 of the Care Homes Regulations 2001. It is also recommended that the home ensure that full employment histories are obtained. It was also noted that the documentation relating to a disciplinary did not appear in a staff file. The Area Manager stated that he would investigate this as the disciplinary did take place. At the time of the inspection the Manager explained that the home was in the process of auditing the training that staff have completed and was developing individual staff training files. Following the inspection, copies of completed training records have been forwarded to CSCI. All staff undertake Induction training. The Inspector was advised that the Company has a ‘set date’ for all newly appointed staff to attend an induction. The induction includes mandatory training and specialist training. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 22 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): 39 & 42 KEY STANDARD 27 WAS NOT ASSESSED AT THIS INSPECTION AS THERE IS A VACANCY FOR THE POST AS REGISTERED MANAGER Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home wishes to ensure that a quality service is provided and has conducted service user and relative questionnaires. The home has taken appropriate measures to promote the health and safety of staff and service users. EVIDENCE: Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 23 As part of the home’s quality assurances, in November 2006 the home conducted a service user questionnaire and in May 2006 a relative/advocate questionnaire. The Inspector viewed the responses to the questionnaires. These generally provided very positive feedback from the service provided. It is unclear if the results of these questionnaires have been published to interested parties. It is recommended that this be the case. The Inspector also recommends that the home conduct questionnaires with other professionals such as care managers, GP and psychology services. The Inspector viewed documentation in relation to health and safety: Fire Safety: Weekly checks are conducted on fire points and emergency lighting. These were last conducted on 05/02/07. The annual service of the fire system and emergency lighting was conducted on 21/09/06. The fire equipment was serviced on 25/04/06. Staff are provided with regular updates on fire safety training. Fire drills are completed on a regular basis and appropriate records maintained. The Inspector spoke to a number of service users who were able to demonstrate what they would do if the fire alarms sounded. Hot Water: The Manager stated that all hot water outlets have thermostatic valves fitted to ensure that the temperature does not exceed the recommended levels. The Inspector recommend that the home keep records of regular testing of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 44 degrees centigrade for baths and 43 degrees centigrade for showers. Electrical Hardwiring Certificate: This is dated 20/01/04. Guidance from the Health and Safety Executive states that electrical hardwiring certificates are usually valid for five years within a care home. Portable Appliance Testing: Annual testing took place on 25/02/06. The home has ensured that epilepsy monitors are well maintained and are tested weekly. Accidents: The Manager stated that records are kept of all accidents. The Inspector viewed records relating to these and recommend that the Manager sign all records of accidents as part of the audit process. COSHH: The home has a policy in relation to this. All products are stored securely. Fridge/Freezer: The home keeps daily records of fridge and freezers and keeps food probe records. Risk Assessments: The home has a detailed risk management policy. The Inspector viewed a number of individual and environmental risk assessments. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 24 Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 25 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 X 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 3 X Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 26 YES 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 Timescale for action 19/03/07 2 YA23 18 (c) 3 YA34 18 The Manager must ensure that risk assessments are completed in relation to health and safety, if restrictions are imposed on service users. The home must ensure that staff 30/04/07 receive training in abuse awareness/protection of vulnerable adults. The Manager must ensure that 19/03/07 the recruitment files contain the required documentation as listed in Schedule 2 of The Care Homes Regulations 2001. 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 2 3 Refer to Standard YA6 YA6 YA9 Good Practice Recommendations Wherever possible service users should be involved in the development of their care plan and sign their agreement. The rewards systems used in the home should be clearly outlined in care plans, including dates for review. Risk assessments should be conducted in relation to DS0000058862.V325159.R02.S.doc Version 5.2 Page 27 Holly Tree Cottage 4 5 6 7 YA15 YA23 YA23 YA34 8. YA39 9 YA42 10 YA42 service users being involved in activities that further promote independence. The home should give consideration in ways in which communication with relatives could be further improved. The Manager should countersign all incident records as part of the audit process. As part of the audit process the Manager should regularly check individual service user bank statements to ensure that they reflect the withdrawals and deposits made. The Manager should a copy of proof of identity be maintained for each staff member and that staff recruitment records include a full employment history so that gaps in employment may be explored. The home should publish the results of the recent service user and relative’s questionnaires to interested parties and should conduct questionnaires with other professionals such as care managers, GP and psychology services. The home should keep records of regular checks of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 44 degrees centigrade for baths and 43 degrees centigrade for showers. The Manager should countersign all accident records as part of the audit process. Holly Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Tree Cottage DS0000058862.V325159.R02.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!