Inspection on 13/04/06 for Hollycroft

This inspection was carried out on 13th April 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollycroft 14/06/07

Hollycroft 20/12/05

Hollycroft 06/09/05

Hollycroft 21/02/05

Hollycroft 05/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Hollycroft 90 Church Street Langford Bedfordshire SG18 9QA Lead Inspector Andrea James Unannounced Inspection 13th April 2006 10:00 Hollycroft DS0000014915.V288278.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 Hollycroft DS0000014915.V288278.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. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hollycroft Address 90 Church Street Langford Bedfordshire SG18 9QA 01462 701273 01462 850689 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.hft.org.uk Home Farm Trust Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Holly croft was a large detached house in the village of Langford that had been adapted to provide accommodation for eight adults with learning disabilities. The house was situated in the main street of the village and there were pubs, church and shops in close proximity. There was an infrequent bus service to the nearby town and the home had two domestic style vehicles for the use of the service users. The adaptations to the house resulted in six single rooms on the first floor with two bathrooms and a separate toilet and staff accommodation. Two further bedrooms were provided on the ground floor with a bathroom, separate toilets, two lounges, dining room and kitchen. A laundry room was provided on the ground floor but access to this was from the garden. The large rear garden was enclosed and overlooked open fields. To the front and side of the building was parking space for five or six vehicles but some manoeuvrability was required if the parking space was full. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 13th of April 2005, 4 months after the last inspection. The inspection lasted for a duration of 4.5 hours and the acting manager and the new Registered Individual was available for the inspection process. The processes followed a case tracking methodology where some of the service users were randomly selected to inspect. These service users, their relatives and staff were spoken to and their files and documentation inspected in detail. On the day of the inspection several relatives visited the home and gave their views about the service provided to the service users. What the service does well: What has improved since the last inspection? Since the last inspection the home had worked hard in order to improve on the environmental standards that at the last inspection caused concerns to the safety and welfare of the service users. These included better procedures for controlling and testing the water temperatures in the home, the refurbishment Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 6 of a new shower room and arrangements to make better use of the garden facilities. The procedures for recording service users finances used on a daily basis had improved and where necessary two staff signed for service users monies. There was evidence to suggest staff were receiving regular supervision, which resulted in better communication between management and some of the staff team. The home engaged an independent auditor to undertake various fire assessments in order to identify potential hazards and had hoped to have receive their report in order to action recommendations identified but to date it had not been received. 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. Hollycroft DS0000014915.V288278.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 Hollycroft DS0000014915.V288278.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): 1,2,3 and 5. “Quality outcome in this area was poor. Service users and their relatives were provided with sufficient information in order to make a choice if they wanted to live at the home and satisfactory contractual agreements were in place”. The home was poor at assessing and ensuring the needs of the service users needs were met. EVIDENCE: The service users and relatives spoken to said they were provided with sufficient information to decide if they wanted to live at the home and they were also given the opportunity to visit the home prior to admission. Those spoken to said they felt the home handled their transition satisfactorily and were given all the relevant documentation. The documents inspected suggested that all service users were provided with a contract and copies of which were signed and dated. The documents inspected suggested no assessments have been developed for the service users and since the last inspection. The staff team and manager said they had not had the time to do this but would carry out the process in the near future. The importance of identifying the needs of the service users was explained to the manager. Hollycroft DS0000014915.V288278.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): 6,7,8 and 9. “Quality in this outcome was poor. The personal needs, risk assessments and future objectives were not identified for the service users in the home”. Service users were encouraged to take risks in developing their lifestyles but these were not documented as a part of the service users care intervention. EVIDENCE: No development was made to the care plans since the last inspection and as a result service users care was inconsisitent and resulted in the some staff feeling service users needs were not being met and that service users were not consulted about the care they recieved. The home failed to develop the risk assessments for service users and as a result service users safety could be compromised. Relatives felt happy with the care the service users received and said they were consulted about big changes in the service users lives. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 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 the following standard(s): 11,12,13,14,15, 16 and 17. “Quality in this outcome area was good. This judgement was made using information received from service users who spoke about the quality lifestyle they were able to live, they were given the opportunity for personal development, to engage in age appropriate and cultural, social, and sexual activities. They were also encouraged to develop community skills, and maintain a healthy diet”. EVIDENCE: Service users spoken to said they enjoyed their lifestyles, they gave example of places they have been, and future plans for example holidays and college placements. Service users were encouraged to maintain a healthy diet and were able to assist with the purchase and preparation of meals on a daily basis. They were also encouraged to carry out domestic skills in the cleaning of their rooms and communal areas of the home. This was done on a rota basis and service users said they were happy with this arrangement. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 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 the following standard(s): 18,19,20 and 21. “Quality in this outcome area was adequate. The personal and health care support received by the service users were satisfactory as a result service users welfare was protected and they were safe”. The home needed to ensure the wishes of the service users in the event of their death are recorded. EVIDENCE: Service users daily records and various letters to external professionals suggested that the service users had regular visits from healthcare professionals. One relative said the home was good at trying to get the best dental care for her son and they worked together in order to achieve this. The staff were observed to take some service users to various appointments on the day of the inspection. Due to the lack of information provided on the care plans it was not clear if the home was addressing the entire healthcare needs of the service users. Staff commented that some service users emotional and physical needs were not being addressed. The home had a death and dying policy but failed to individually document the wishes of the service users in the event of terminal illnesses or death. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23. “Quality outcome in this area was adequate. The home’s complaints procedures and policies created an environment that service users and relatives felt comfortable to complain should the need arise, however some processes in the home failed to protect the service users from abuse and as a result service users could be open to abuse from a financial perspective”. EVIDENCE: The home had a complaints procedure and service users, relatives and staff said they were happy that should they complain their complaint would be dealt with satisfactorily. The home has had no formal complaints since the last inspection. The daily recording of service users money had improved and reciepts were seen for all transactions. It was concerning that service users were still expected to pay for staff when they accompany them whenever they wanted to attend actvities outside of their programmed actvities. Service users also had to pay for transport when the homes transport was not available and as a result staff commented that this was not in line with current policies and procedures. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 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 the following standard(s): 24,27,28,and 30. “Quality outcome in this area was good. The home created a safe and hygenic place where service users could be comfortable”. EVIDENCE: The home was warm and welcoming and kept tidy by the service users and staff. Their were no unpleasant odours identified and good standards of hygiene were observed. The home had refurbished the bathroom into a modern shower room and service users were happy to use this facility. The toilet and bathroom facilities were satisfactory to meet the needs of the service users. The home had replaced several windows and kept regular checks to ensure hot water temperatures did not exceed the required temperatures. Plans were in place to replace other windows and install control valves that will ensure all service users will be able to regulate the heat in the home.Currently three service users bedrooms were still in need of having control valves fitted to their radiators. Their was still a need to clean or replace the communal carpets and make good the paint work in the communal areas on the first floor. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 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 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): 31,32,34,35 and 36. “Quality outcome in this area was poor. The judgement was made using available evidence and included communication between staff and service users”. Staff were qualified to provide care to the service users but staff moral was low which could affect the care the service users received. The home’s recruitment procedures needed further development to ensure the safety of the service users. EVIDENCE: The home had a good core of staff that provided stable care for the service users. Relatives felt confident that the staff were able to relate to the service users and effectively meet their needs.They gave examples of how staff were able to positively relate to the service users. The staff received regular training and a large number of staff had obtained their NVQ level 2 in care.There was also plans for future training to ensure staff are able to meet the needs of the service users. Staff explained the Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 15 contents of some of the training courses they had attended and how it reflected in better care practices for the service users. Ther home failed to ensure satisfactory recruitment records are kept in the home and as a result service users safety could be compromised. The manager said the records were kept at the resource centre and she had made arrangements for these to be transferred to the home but had not yet been processed. Staff moral was low as some staff felt they were not listened to by the manager, examples given by staff was that they suggested foreign holidays for service users and this was denied and that when problems with transport arose the manager did nothing about it. The manager explained that procedures were in place for reporting vehicle problems and staff were not always aware of budget constraints that would prevent some service users having holidays abroad. It was obvious that some staff were very not happy with some of the changes imposed by the manager. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 16 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): 37,38,39,42 and 43. “Quality in this outcome area was adequate. The judgement was made using the available evidence collected and a site visit to the service”. The home received good leadership, that benefited the service users but further development was needed to ensure the managers fitness to manage the home was in line with the Commissions requirements and as a result the home was not meeting the conditions of their registration. The home had made some progress on their quality monitoring system but further development was needed to ensure all aspects of the services the home provides is regularly audited and improved. The home’s health and safety procedures were satisfactory and as a result service users were safe. EVIDENCE: Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 17 The manager appeared to have a good understanding of the management aspects of the home and changes implemented appeared to benefit the majority of the service users. The manager was yet to submit her application for registration and as a result the Commission was not given to opportunity to assess her fitness. The manager appeared to have some staffing issues that may affect the service delivery to the staff but she received the support from the Registered Individual in order to work through the various issues. The home was dealing with various staff complaints and disciplinary procedures. The home had also addressed their quality assurance monitoring systems by sending and collating questionnaires that reflected relatives, service users and external professional views of the quality care they provided. This process could be further developed by ensuring all aspects of the home received such monitoring and evaluation in order to improve service delivery. The home had satisfactory health and safety procedures. On the day of the inspection the fire records and procedures were inspected and found to be satisfactory. Service users spoken to said they received regular fire evacuations. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 18 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 1 3 3 4 X 5 3 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 2 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 2 3 3 2 X X 2 2 Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 19 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 YA2 Regulation 14 (1)(a) (b) (c) (d). 14 (2) (a) (b) 15 (1) Requirement Timescale for action 30/06/06 2. YA6 All service users must receive a full and comprehensive assessment of need by a person qualified to do so and these must be implemented as a part of their care package. All service users must have a full 30/06/06 and detailed care plan that illustrates the care interventions to be carried out for all identified needs. Previous time scales of: 30/4/05,30/11/05,28/02/06. All care plans must be reviewed and updated on a regular basis. Previous timescale: 30/11/05,28/02/06 30/06/06 3. YA6 15(2) (b) (c) 4. YA6 13 (4) (b) All identified risks must be risk 30/06/06 assessed and satisfactory interventions implemented for all service users. Previous timescales of: 30/04/05,30/11/05,28/02/06 Arrangements must be made to 30/06/06 ensure the healthcare needs of the service users are assessed and implemented as a part of their DS0000014915.V288278.R01.S.doc Version 5.1 Page 20 5 YA19 14 (1) Hollycroft care package. 6 YA21 17(1) (a), 14 (1) (d), 12 (2) 13 (6) The wishes of the service users in the event of their death or terminal illness must be recorded where appropriate to ensure their wishes are maintained in areas of health and welfare. Arrangements must be made to ensure correct policies and procedures are implemented to protect service users from financial abuse. In particular arrangements must be in place to ensure service users monies does not pay for staff while on service users activities. Arrangements must be made to ensure all staff recruited in the home have satisfactory application forms and clearances on file and are kept at the home. Previous timescale: 30/11/06,28/02/06 Arrangements must be made to risk assess the home against potential fire hazards. This information must be kept under review. Previous timescale: 30/10/05,28/02/06 30/07/06 7. YA23 30/06/06 8 YA34 19 (1) 30/06/06 9. YA42 23 (4) (a) 30/06/06 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 YA23 Good Practice Recommendations Arrangement should be made to ensure all identified abuses follow the appropriate procedures to include reporting incidences to the Commission and Social services department. Arrangements should be made to ensure good personal DS0000014915.V288278.R01.S.doc Version 5.1 Page 21 2 Hollycroft YA36 3. 4 YA43 YA39 and professional relationships are maintained between staff and the management team and staff feels supported in their roles. Arrangements should be made for the manager to submit her application for registration. The quality monitoring systems should be developed to ensure all aspects of the home are reviewed on a regular basis. Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. Extracts may not be used or reproduced without the express permission of CSCI Hollycroft DS0000014915.V288278.R01.S.doc Version 5.1 Page 23 - 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!