CARE HOME ADULTS 18-65
Hollycroft 90 Church Street Langford Bedfordshire SG18 9QA Lead Inspector
Andrea James Unannounced Inspection 20th December 2005 10:00 Hollycroft DS0000014915.V276160.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.V276160.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.V276160.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) Home Farm Trust Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th September 2005 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.V276160.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 20th of December 2005, 3 months after the last inspection. The inspection lasted for duration of 4.5 hours and the acting manager was present throughout the inspection process. The inspection process followed a case tracking methodology where samples of the service users were randomly selected to inspect. These service users were spoken to and their files inspected in detail. The care staff available were also spoken to but no relatives or visitors to the home were available on the day of the inspection. This was the second inspection in the inspection year and as a result some standards met in the last inspection were not inspected on this occasion. It is therefore recommended that both reports be read in conjunction in order to gain a full understanding of the home’s performance. What the service does well:
The home provided satisfactory standards of care to 8 service users with learning disabilities. They encouraged service users to maximise their independence where possible. Service users spoken to said they enjoyed living at the home and spoke positively of the various activities and opportunities available to them. On the day of the inspection all the service users were preparing to attend a local hotel for their Christmas meal. The service users appeared happy and relaxed in their environment. Some service users were observed positively interacting with each other and the staff team. They independently accessed the kitchen facilities and were encouraged using a rota to partake in all areas of domestic skills. All service users attended day care facilities including colleges. Service users spoke positively about the staff and the support they gave them. One service user said the staff had a good sense of humour. The homes medication procedures were satisfactory. The home offered staff training on several areas that ensured the skills and experience of the care staff were developed and as a result the needs of the service users were being met. Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
The home should ensure that all service users have a comprehensive care plan that details the care interventions required for all identified needs. The documents must also be reviewed on a regular basis with satisfactory risk assessments. Further development is needed with the procedures of recording service users financial records. The broken shower remained out of use since the last inspection and as a result sufficient bathing facilities were not made available for the service users. The home had not made provisions to maintain stable levels of heating in the home and as a result the hot water and thermostat radiators in the home needed regulating. Some hot water taps were dispensing water that exceeded 56 degrees centigrade while other hot water taps were too cold to offer comfort to the service users. The same was observed with the heating of the home where some areas of the home were too hot and others too cold. The service users spoken to said
Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 7 they often felt either too cold or too hot. The radiators in the bedrooms also failed to have individual thermostat control valves and as a result service users were unable to regulate the temperatures in their rooms. The home also needed to make further development their recruitment procedures to ensure all employees have satisfactory information that substantiate their authenticity, and that these should be kept in the home. The home had a death and dying policy but no records were kept on file of the service users wishes in the event of their death. The organisation should make arrangements that the acting manager’s application for registration is submitted to the Commission for Social Care Inspection. The commission would like to thank the service users, care staff and the manager for their co-operation in the inspection process. 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.V276160.R01.S.doc Version 5.1 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.V276160.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Satisfactory processes were in place to ensure the home was able to meet the needs and aspirations of the service users, as a result service users expressed that they were happy in the home. EVIDENCE: Service users spoken to said they were happy in the home and felt that their needs were being met. The records seen demonstrated that service users wishes were recorded through regular reviews and actioned where possible by the staff team. Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7. The home was poor at identifying and recording the needs of the service users in the care plans as a result service users needs could not be assessed as met because the care interventions were not satisfactorily recorded. EVIDENCE: The home had made no improvements on the information available in the service users care plans since the last inspection. The care plans viewed had no evidence that the plans had been reviewed. There were however, good daily notes recorded by the staff team and headings were available to suggest satisfactory implementation of care could be achieved. The service users spoke of various areas of care that was being offered to them but these were not recorded in the care plan documentations. The home also encouraged service users to take necessary risks but there were insufficient risk assessments in place to ensure service users safety would not be compromised. Where risk assessments were available they had not been reviewed for over a year.
Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion but were met on the last inspection. (See previous report). EVIDENCE: Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 12 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): These standards were assessed and were met at the last inspection and as a result were not inspected on this occasion. (See previous inspection) EVIDENCE: Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 13 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): 23 The homes processes in safe guarding service users finances needed further development and as a result service users could be open to financial abuse. EVIDENCE: The home had made improvements to their financial transactions for service users by ensuring that where possible receipts were obtained for transaction. Further development was needed to ensure that two signatures are available for all financial transactions where service users money’s are taken. The signatures should also be on the petty cash vouchers used by the home. Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 14 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 and 30. The home was clean and free from offensive odours but some standards of the environment was poor, as a result service users safety and comfort was compromised. EVIDENCE: The home had made efforts in addressing outstanding requirements by replacing 4 of the service users windows. The shower room identified from the last two inspections had not been actioned which resulted in service users having insufficient bathing facilities. The staff and service users commented that the boiler system in the home needed to be addressed as they were experiencing uncomfortable temperatures throughout the day and night. The radiators within the home had no thermostat control valves and as a result service users and staff were unable to regulate the temperatures in individual rooms, which resulted in either having to turn the entire heating system off or enduring the sweltering heat. Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 15 The situation also affected the hot water system in the home. On the last inspection the acting manager said the registered providers were due to install a booster system to the boiler but this had not been actioned. This resulted in various degrees of hot water being dispensed, which could also cause harm to service users due to the high levels of heat recorded. The home was left an immediate requirement to address the hot water problem and subsequently actions have been taken to ensure service users safety until the problem is resolved. The home was free from offensive odours but the carpets in the communal areas of the home had not been cleaned since the last inspection. Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 16 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): 31,34, 35 and 36. The home had a good core of staff that appeared dedicated to meeting the needs of the service users, as a result service users were confident that the home could meet their needs. The home’s recruitment procedure needed further development. EVIDENCE: The home continued to provide continuity by maintaining the same staff team. The manager commented that she had appointed a new senior and felt that the restructure would further benefit the service users. Concerns were raised about the manager’s approach to some care staff, staff commented that they felt bullied and as a result staff moral was affected. Staff commented that they did not have regular staff meetings or supervisions. The home failed to have satisfactory information for new care staff that would ensure service users are protected by the home’s recruitment policy. The home ensured that care staff received satisfactory standards of training. Care staff spoken to said they received training in medication awareness and were scheduled to undertake further training in January 2006. Training records suggested care staff had undertaken various mandatory training and other areas of training in meeting with the needs of the service users.
Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 17 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): 37,39,42 and 43. Satisfactory processes were in place to ensure the home was well run, service users were involved in the monitoring and development of the home and management was competent in taking responsibility for the service, as a result the service users could be confident that the home would meet their needs. Some aspects of health and safety were compromised and as a result service users needs were not met. EVIDENCE: The manager appeared settled in the management aspects of the home. The manager felt that she was challenged because of the new changes that have been implemented but feels she has managed to maintain a good working relationship with the staff team. The manager had not yet applied for her registration and as a result was not working within the regulation of the care standards requirements. Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 18 The service users spoken to said they liked the new manager and in-house surveys demonstrated that service users were happy with her management styles. The home had satisfactory health and safety policies and procedures were not in accordance with health and safety regulations. The service users were exposed to excessive hot water temperatures and some risk assessments to maintain service users safety were not completed. Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 2 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X X X 2 Hollycroft DS0000014915.V276160.R01.S.doc Version 5.1 Page 20 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 YA6 Regulation 15 (1) Requirement All service users must have a full 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 All care plans must be reviewed and updated on a regular basis. Previous timescale: 30/11/05 All identified risks must be risk assessed and satisfactory interventions implemented for all service users. Previous timescales of: 30/04/05 30/11/05 At least two signatures must be obtained for any money being dispensed to the service users, to ensure accountability. Previous Timescale: 30/10/05 Arrangements must be made to ensure hot water taps does not distribute water in excess of 43 degrees centigrade. Arrangements must be made to regulate all hot water taps to ensure comfortable
DS0000014915.V276160.R01.S.doc Timescale for action 28/02/06 2. YA6 15(2) (b) (c) 13 (4) (b) 28/02/06 3. YA6 28/02/06 7. YA23 13 (6) 28/02/06 8. YA24 13 (4) (a) 28/12/05 9. YA24 12 (4) (a) 28/02/06 Hollycroft Version 5.1 Page 21 10. YA24 16 (1) 11. YA27 23 (2) (j) 12. YA34 19 (1) 13. 14. YA36 YA42 18 (2) 23 (4) (a) temperatures of water are being distributed from all taps. Arrangements must be made to ensure the boiler system and temperature control mechanisms within the home are improved to ensure service users are able to individually regulate the temperatures in their rooms and communal areas. Arrangements must be made for the broken shower being used for storage to be repaired and used for its original purpose. Previous timescale: 30/4/05 30/11/05 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 Arrangements must be made to ensure all staff receive regular supervisions. 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 30/01/06 30/03/06 28/02/06 01/03/06 28/02/06 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 YA37 Good Practice Recommendations Arrangements should be made for the manager to submit her application for registration. Hollycroft DS0000014915.V276160.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.V276160.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!
