Inspection on 14/06/07 for Hollycroft

This inspection was carried out on 14th June 2007.

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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollycroft 13/04/06

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 Hollycroft 90 Church Street Langford Bedfordshire SG18 9QA Lead Inspector Mr Ian Dunthorne Unannounced Inspection 14th June 2007 15:00 Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollycroft Address Hollycroft 90 Church Street Langford Bedfordshire SG18 9QA 01462 701273 01462 850689 julia.keens@hft.org.uk www.hft.org.uk Home Farm Trust 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) ** Post Vacant *** Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th April 2006 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 people living at the home. 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. Information regarding the home’s range of fees and the manager’s figure provided in the pre-inspection questionnaire in February 2007 stated that the weekly fee ranged from £513 to £530.20. Any additional fees not included were not specified within the information provided. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days amounting to 6.25 hours during the afternoon & evening on the first day and during the afternoon on the second day and it was unannounced. Prior to the inspection time was taken to review the information gathered since the last inspection and plan this inspection visit. This report also includes feedback from people living at the home obtained from postal questionnaire surveys. The inspection included a tour of the communal areas and bedrooms, inspection of certain records, discussion with staff, discussion with people who used the service and lived at the home and observation of the routines of the home. No relatives were available during the inspection to speak with. The method of inspection was to track the lives of several people who used the service and lived at the home. This was done by speaking to them about the service they receive, observing their life in the home, talking to staff and reviewing their records. The person managing the home was not available during this inspection and was at the time of the inspection not registered with the ‘Commission for Social Care Inspection’ (CSCI) as a fit person to manage the home. However there was evidence that the person managing the home had submitted an application to register as a fit person and was undergoing the registration process with CSCI’s regional registration team. What the service does well: All staff were observed throughout the inspection to have formed good relationships and a good rapport with service users. The service enables people using the service to be given a choice and make decisions about their lives at the home, with the support of staff if necessary. One person who lived at the home and used the service commented, “I have a choice, I am happy here and I feel comfortable and proud to live here”. The meals provided in the home were home cooked, balanced and varied and suited the tastes of the people who used the service, who were supported to plan, prepare and cook their chosen menu’s. One person who used the service said, “I like the food here, I help at tea to wash up and help in the kitchen”. The home and staff supported the people who used the service to pursue meaningful leisure activities, relationships & community links. The complaints procedure was accessible and in a format suitable for people who used the service, one person who used the service commented, “If I Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 6 wasn’t happy I would go to my keyworker, the manager or to CSCI & I would feel happy to do that”. People who used the service were protected and safeguarded from abuse, by effective systems & procedures in place, combined with training and staff knowledge within the home. What has improved since the last inspection? What they could do better: Some of the things that the home could do better include: • • • • • • Making sure that all the necessary staff employment and recruitment records and checks are available and are kept at the home. Assessing the risk of fire hazards at the home regularly, to help protect those who lived and worked there from harm. Making sure that customers are clear about anything they will have to pay for. Ensuring that medication is managed properly and safely by the home. Providing someone suitable to sleep for staff. Making sure that all the information about the home is up to date, accessible and available. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 7 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. Hollycroft DS0000014915.V338369.R01.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 Hollycroft DS0000014915.V338369.R01.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, 2, 3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided people who used the service with a written contract of terms and conditions with the home in a suitable format. However the home failed to identify in the contract, the fees payable and what it covered and did not cover, which did not allow all the people who used the service to be aware of the fee and what they may need to pay, including that of any additional extras. EVIDENCE: The majority of the respondents to the postal questionnaire surveys sent to the people who used the service and lived at the home, said that they felt they were given enough information about the home to make an informed choice about whether to stay there. However, there was no evidence that the homes statement of purpose and service user guide had been reviewed since January 2004, which was the date of the one available in the home. Therefore the information detailed within it was found to be old and out of date. In addition the information was not available in a suitable format for all the people who used the service. The homes last inspection report was available within the home, but only accessible upon request. The staff explained that this was because some people who lived at the home and used the service may remove the inspection Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 10 report if displayed. However there was no evidence at the time of the inspection, demonstrating that people who lived at the home, relatives and visitors had been informed of this, or any document telling them how they could access the last inspection report. No new prospective people to use the service had been admitted since the last inspection. Therefore this standard could not be fully assessed. However there was evidence included within the records of the people whose lives were tracked, which supported that the home had undertaken a full assessment of needs for each of them. The needs assessment was also supported by a health and social services assessment. The home had developed a care plan from the assessment of needs. The home demonstrated that the method and system for doing so provided a satisfactory form of assessment. The method of assessment involved the person who used the service, the family and other individuals referred to as part of the person who used the services, care management process. There was also evidence that the home had regularly reviewed the assessments of need. The home was able to demonstrate that it could meet the assessed needs of people staying at the home. Staff individually and collectively demonstrated that they had the skills and experience to deliver the service and care which the home said it could provide. Staff were observed communicating with people using the service in different forms of communication to suit their individual preferences and needs, which included ‘Makaton’ sign language. There was evidence that the people who used the service whose lives were tracked had written contracts with the home. This included a statement of the terms and conditions, which had been signed by them or their representative, and the manager of the home. There was evidence that the home had introduced contracts in a format appropriate for the needs of most of the people who used the service. The home had failed to include fees charged within the terms and conditions and any additional fees or ‘extras’, which may not be included in those fees, were also not specified. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 11 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, 8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable risk assessments were completed by the home, to ensure people who used the service were protected whilst their independence was promoted. However further development was needed to ensure that the person who used the service, agreed to their risk management strategy, by ensuring their involvement and consultation are recorded. EVIDENCE: A sample of care plans and supporting documentation for people who used the service were examined and found to contain suitable and sufficient information to help meet their changing needs and personal goals were identified and reflected in their individual plan. The plan was made available in a format the people who used the service could understand and a person centred planning (pcp) approach was used successfully. A suitable keyworker was allocated for each person who used the service and lived at the home. The plans had been reviewed at regular intervals and there was clear evidence that people using Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 12 the service had been included and consulted in drawing up the plan. However one person who used the service whose life was tracked as part of the inspection had signed their care plan. However due to their level of communication and understanding it was evident they did not understand what they had signed, staff that were spoken with verified this. Despite this, there was no evidence on the care plan that the person’s family, representative or advocate as appropriate had been consulted as part of this process to involve them in completing and agreeing with the care plan in this instance, as the person’s representative in consultation with them. Almost all respondents to the postal surveys said they either always or usually made their own decisions about what to do each day. There was evidence from speaking with people who used the service and records examined that they were assisted as necessary to make decisions about their daily lives. Some information provided by the home was in a suitable format to support service users to make decisions about their lives whilst staying at the home. People who used the service and lived at the home were supported by staff to participate independently and confidentially in an advocacy service provided if they wished, who visited each month. Staff were observed communicating in ways appropriate to each individual person who lived at the home and used the service to enable them to make an informed decision in a way that person could understand. One person using the service commented, “I have a choice here”. It was evident by observation, that people who used the service and lived at the home were offered the opportunity and participated in the day to day running of the home and contributed towards any proposed changes within the home, to influence any decisions reached. One person who used the service said, “I hold the residents meetings each week now, I enjoy it, I like taking the residents choices and doing the menu, we go shopping, prepare the food and one of us does the shopping”. The home had a notice board for people who lived at the home, which provided information in a suitable format about various activities, services, policies and procedures. There was evidence that people who lived at the home and used the service were consulted about all aspects of life within the home at their meetings that were held regularly. There were suitable risk assessments in place as part of the homes risk assessment strategy to enable people who used the service and who lived at the home to take risks supported by staff and they had been regularly reviewed. However, there was not always evidence that the risk assessments had been agreed in consultation with person who used the service by signing them in the space provided for this on the document used at the home. The home was able to demonstrate that people who used the service and lived at the home were given information and supported to protect their personal safety, to help them avoid limiting their independence, activities or choices. A person who used the service was supported by the home as part of their lone Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 13 travelling risk assessment and strategy, to use a mobile phone and they knew how to use it in an emergency. People who lived at the home were able to attend a ‘Life Skills’ course at a local college to support this. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 14 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. The home and staff supported the people who used the service to pursue meaningful leisure activities, education, relationships & community links. This enabled them to maintain choice, independence and provided them with an opportunity for personal development. EVIDENCE: The home supported people who used the service and lived at the home to attend college and many were also supported by the home to regularly visit a local resource centre, which provided planned educational and training activities, during the day and evening. The home’s notice board for people who used the service displayed information about local activities. People who used the service were able to access and use local public transport facilities available close to the home; one person who used the service used public transport to travel to college for example. Service Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 15 users were supported by the home to attend church when they wished to. The home demonstrated that it had a flexible approach to supporting people who used the service inside and outside of the home during weekdays and evenings. People who used the service were supported by the home to pursue their own interests and hobbies. People who used the service who were spoken with said they enjoyed their lifestyles, they gave example of places they had been, and future plans for holidays one person said, “I went clothes shopping with my keyworker for my holiday this week, I am going to Mallorca, it’s where I wanted to go”. There was evidence that the home supported people who used the service to maintain family links and friendships inside and outside the home, in accordance with their wishes. This evidence was supported by people who were spoken with who lived at the home and who also said that their families and friends could visit at any time. Families and friends had been involved in planning and arranging holidays with the people who used the service’s agreements. Staff were observed knocking on bedroom doors of people who used the service and lived at the home before entering and waiting to be invited into their bedrooms. People who lived at the home undertook responsibility for housekeeping tasks, which were specified within individuals’ people’s, care plans and were clearly displayed on a notice board, which was discussed at the meetings for those people who used the service. Staff were observed using the preferred name of those people who used the service as recorded in their care plan and speaking with them, involving them and not just to each other. People who used the service were observed sitting where they liked and moving around without restriction. One person using the service was observed being supported by a staff member to do their laundry who commented, “I do all my own washing and ironing”, which was tracked to their care plan and a completed risk assessment for this activity. Evidence examined, which included the menus and from speaking with people who used the service, demonstrated that they enjoyed well prepared and presented, home cooked and appetising food, in suitably sized portions. Although the menus were not in a suitable format to enable all people who used the service to make an informed choice. However, menus were discussed and agreed with the people who used the service each week, which was held by one of the people who lived at the home and used the service. Those people who used the service and who were spoken with said they had participated in preparing for, planning the menu for the week, shopping and laying the tables. All the people who were spoken with who used the service commented positively about all aspects of the food at the home. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 16 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 & 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for the administration of medication were satisfactory. However further development was needed to ensure that records of administration completed by the home were clear and accurate; that people who were supported with their medication had agreed to this and that staff knew how to access the home’s medication policy to safe guard the health and well being of people who used the service. EVIDENCE: People who used the service who were spoken with said they enjoyed living at the home and that they felt supported by the staff. Records viewed suggested people who used the service received personal support in the way they preferred and most were encouraged to maximise their independence. This was supported by observations and discussions held with the people who lived at the home and used the service. Each person who used the service had a key worker, who they were each able to identify and those people who used the service who were spoken with said they were happy with the support from them and the relationship they had developed with them. All respondents to the postal surveys said that they were treated well by staff and several positive Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 17 comments were made. One person who used the service commented, “It’s relaxing here and the staff are comforting and I get on well with my keyworker”. There was evidence that the home accessed outside healthcare professionals and services as required; in order to support and meet the healthcare needs of the people who used the service. A variety of healthcare monitoring charts were in use, including health action plans. The home had ensured that care staff were trained in medication and the procedures implemented suggested that the safety of people who used the service was being maintained in most areas. Staff were observed supporting people who used the service with administering medication to them and appeared competent and confident. Individual risk assessments had been completed for medication by the home for people who used the service, however the home had failed to ensure that those people signed them to acknowledge, their involvement, consultation and agreement. The staff at the home were unable to locate the home’s medication policy during the inspection, which was of concern if they needed to in the event of an incident in which they may have needed to refer to it. The medication administration record of one person who used the service demonstrated evidence of a handwritten entry made to it by a staff member, which had neither been dated nor signed by them to authenticate this record. The home did not have any people who used the service receiving any controlled drug medication at the time of the inspection; therefore those aspects of this standard could not inspected. The home had a death and dying policy and individually documented the wishes of the people who used the service in the event of terminal illnesses or death in a tactful and sensitive way. A record called an ‘End of Life Book’ had been implemented by the home and was completed by the key worker with the person who used the service over a period of time. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting people who used the service were good and the home maintained an effective approach to complaints within a satisfactory system. This helped to ensure people who used the service were protected from abuse and to feel that they views were listened to and acted upon. EVIDENCE: The home had a satisfactory complaints procedure that ensured people who used the service felt their views were listened to and acted upon. The complaints procedure was produced in a format appropriate for people who used the service to understand and access. There had been one recorded internal complaint since the last inspection, evidence demonstrated that it had been managed in a way that ensured the person involved was listened to and their views acted upon which complied with their policy and evidence of the process was recorded. People who used the service, who were spoken with, were aware of the home’s complaints procedure and felt comfortable and confident to use it and that they would be listened to. All respondents to the postal surveys said they knew how to complain and who to speak to if they weren’t happy, those people who used the service verified this evidence that were spoken with during the inspection. The home had a ‘Safeguarding Adults’ policy in place, which included whistle blowing and staff spoken to demonstrated they were aware of the procedure. Most staff had also attended abuse awareness training, which included Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 19 ‘Safeguarding Adults’; ‘Safeguarding Adults’ training was also included and formed part of the homes induction process for staff. Since the last inspection there had been one notifiable incident in accordance with the ‘Safeguarding Adults’ policy and guidance, which was reported to CSCI at the time. Evidence examined, supported a process that had been followed to safeguard and protect people who used the service. The homes policies and practices regarding money and financial affairs of people who used the service were generally satisfactory and protected them from abuse. There was evidence that the home had introduced a revised policy for the management of money and finance for those people who used the service and were supported in this area, to improve and ensure robust practices were followed. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 20 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, 26, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was satisfactory. However staff were not provided with suitable sleeping facilities and further development was needed to improve infection control practices in some areas, to maintain a pleasant and safe environment for people who used the service and lived at the home. EVIDENCE: The home provided a homely environment; the building had been sympathetically converted from private houses. The location and layout of the home were suitable to meet the individual and collective needs of the people who lived at the home and used the service. The home was close to local amenities and transport if required. The environmental health department had not visited the home since the last inspection. The local fire service had visited the home in March this year and found that the home did not comply with all fire safety regulations, as the home’s fire risk assessment was not suitable or sufficient. This was a requirement made under ‘Conduct and Management of Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 21 the Home’ set of standards at the last inspection as the premises met the requirements of the local fire service. All the people who used the service and lived at the home that were spoken with as part of this inspection, were happy with their individual bedrooms and they had free access to them. One person who used the service said they had chosen the decoration themselves with the support of the home and their family. People who used the service had been encouraged to bring or choose their own furniture and those bedrooms observed had been personalised to reflect their needs and lifestyle. One person who used the service said that they had everything they needed and wanted in their bedroom and demonstrated great satisfaction in their new bedroom carpet, which they had chosen and had recently been fitted. People who used the service and lived at the home were encouraged to take responsibility to maintain their cleanliness. The homes outdoor space appeared adequate. Kitchen and laundry facilities were suitable and domestic in scale. The laundry was a lockable facility with entry gained by people who used the service with the supervision of care staff, due to ‘Control of Substances Hazardous to Health’ (COSHH) risk assessments and control measures in place to protect people who lived at the home from harm. Staff were provided with unsuitable sleeping and changing facilities when sleeping in, as their sleeping in facilities also became the combined and integrated office for the home and where the manager was based. This arrangement was clearly unsuitable as there was insufficient room for this to be practical and consequently people had no alternative but to sit on the bed as there may be no other suitable alternative available. The home appeared clean and generally free from offensive odours, people who used the service, care staff and night staff were responsible for ensuring this was maintained. However some communal toilets and bathrooms within the home had a communal towel in as the only facility to dry your hands on after washing them. This was not an effective infection control system that was consistent throughout the home. In addition a communal bathmat was on the floor in one bathroom, which also presented a slip and trip hazard and a nonslip mat was evident in a bath, both demonstrated unsatisfactory cross infection practises. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 22 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 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment practises at the home were satisfactory. However further development of the system was required to ensure that all staff’s recruitment records were kept at the home, to ensure that the safety of people who used the service was not compromised. EVIDENCE: Staff spoken to identified varied training which they had undertaken at the home and this was supported by evidence in their training records. There was evidence that some staff had received specialist training to support them to meet the needs of the people who used the service. The percentage of staff qualified at nvq (national vocational qualification) level 2 or 3, was 71 , which was above the minimum required level of 50 . Staffing level numbers within the home were maintained to meet the appropriate ratio based upon the needs of the people who used the service. The home only had a limited and infrequent need for agency use, as they only had a small amount of vacant permanent hours to be recruited for, which were being adequately covered by staff working additional hours and an effective Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 23 team of relief staff for cover arrangement purposes. The home maintained low staff turnover and good retention of staff. There was evidence that regular staff meetings were held at the home. A requirement was made at the last inspection to ensure that satisfactory staff recruitment records were kept in the home. However, it was disappointing to find that this requirement had not been fully complied with. The missing records were subsequently produced as evidence during this inspection, as copies were held centrally and had clearly not been transferred to the home as agreed at the last inspection. Staff files that were examined, demonstrated that the home had obtained satisfactory checks and clearances on staff before their commencement. There was no structured training & development plan for each staff member in place, however staff explained that ‘professional development plans’ will be introduced in the future, which are intended to meet this requirement. There was evidence that new staff received suitable inductions. Evidence examined and staff spoken to demonstrated that staff received supervision regularly, although records examined were only available up to February this year that provided recorded evidence of this. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 24 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): 37, 38, 39, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of the homes health & safety and safe working practice procedures needed further development to ensure service users & staff would be protected from the risk of harm. EVIDENCE: The manager was not present during this inspection. However there was evidence that the manager was qualified, competent and experienced to run the home. The manager had not yet registered with CSCI as explained in the ‘Summary’ section of this report. Some staff demonstrated a feeling of unrest towards the leadership of the home and felt that there was not an inclusive atmosphere. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 25 There was evidence, which supported that the manager used several methods to ensure that staff, people who used the service and their relatives had the opportunity to voice any concerns. Staff said that regular meetings were held with people who used the service, their family and friends of the home, although evidence of this was not examined. The home had developed a quality assurance and monitoring system, from which the home had formulated several action plans from the information it had collected from several sources. The action plans included actions, goals and reviews although no reviews had been undertaken at the time. There was evidence that the home had begun a cyclical system of regularly monitoring and reviewing the views of people who used the service, amongst others. Some records it was noted had a number of entries made by staff who had signed to authenticate care records using their first name only, or variations of their initials only, as opposed to their full names for clear identification purposes. In addition several daily care records and care plans of residents examined, demonstrated that a generic system of abbreviations were used by care staff when recording. Some aspects of the homes health & safety safe working practices, required some improvements to protect people who used the service from potential risk or harm. See ‘Environment’ section of this report. Various records were examined to support adequate compliance with safe working practices, regarding health & safety which included generic risk assessments for the home and various tasks; health and safety audits undertaken, temperature records, maintenance meeting minutes, accident and fire records. The home used a traffic light hazard warning system for storage and control of substances hazardous to health (COSHH) with generic risk assessments for the use of chemicals, which were not always specific to each chemical. As detailed in ‘Environment’ section of this report, the local fire service had visited the home in March this year and found that the home did not comply with all fire safety regulations, as the home’s fire risk assessment was not suitable or sufficient. This was a requirement at the last inspection; therefore it was disappointing to find that there was no evidence to demonstrate that this had been complied with. Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 1 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 2 3 2 2 3 X 2 1 X Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5 (1b) & (1c) Requirement People who use the service must be provided with an individual written contract or statement of terms & conditions, which must include the amount and method of payment of fees and any additional ‘extras’, not included within the fee must be specified. Timescale for action 31/08/07 2. YA20 13 (2) & 13 (4) (b) & (c) When medication is administered 31/07/07 to people who use the service it must be clearly recorded, this will ensure that the records are authenticated and their recorded consent to support them with their medication must also be obtained. All staff must be familiar with the home’s medication policy and how to access it at all times, for referral and guidance purposes. Staff must be provided with suitable facilities for the purpose of changing & sleeping accommodation, as this is needed by staff in connection with their work at the home. Arrangements must be made to DS0000014915.V338369.R01.S.doc 3. YA28 23 (3) (b) 31/08/07 4. Hollycroft YA34 19 (1) 31/08/07 Page 28 Version 5.2 ensure all staff recruited in the home have satisfactory application forms and clearances on file and are kept at the home. Previous timescales: 30/11/06, 28/02/06, 30/06/06 met in part. 5. YA42 23 (4) (a) Arrangements must be made to risk assess the home against potential fire hazards. This information must be kept under review. Previous timescales: 30/10/05, 28/02/06, 30/06/06 met in part. 31/07/07 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 YA1 Good Practice Recommendations Information about the home should be made available in a suitable format for those people who use the service to understand and it should be kept under review and updated as necessary. The homes most recent inspection report should be made available to both the people who use the service and their families. Evidence should be provided that the care plan has been completed with the involvement of the person who uses the service together with their family, friends and / or advocate as appropriate. Risk management strategies should be agreed with the person using the service and this should be recorded. Disposable hand towels should be provided in communal toilets and bathrooms, to ensure effective infection control practices are not compromised. DS0000014915.V338369.R01.S.doc Version 5.2 Page 29 2. YA1 3. YA6 4. 5. YA9 YA30 Hollycroft 6. YA35 The home should ensure that it has a training & development plan, which includes a training & development assessment for the staff team as a whole, which then extends to staff individually. Arrangements should be made to ensure good personal and professional relationships are maintained between staff and the management team and staff feels supported in their roles. Care staff should ensure that they sign documented care records with their full name on each entry and generic use of abbreviations should be avoided, as this can prevent residents understanding information held about them. Arrangements should be made for the manager to submit her application for registration. 7. YA36 8. YA41 9. YA43 Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Hollycroft DS0000014915.V338369.R01.S.doc Version 5.2 Page 31 - 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. 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