CARE HOME ADULTS 18-65
Hollydale Back Lane Clayton Le Woods Lancashire PR6 7EU Lead Inspector
Val Turley Announced Inspection 28th September 2005 09:30 Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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 Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hollydale Address Back Lane Clayton Le Woods Lancashire PR6 7EU 01772 337701 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) Dalesview Partnership Miss Michelle McMillen Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A maximum of 8 service users requiring personal care who fall into the category LD - Learning Disability. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 28th February 2005 3. Date of last inspection Brief Description of the Service: Hollydale is one of two homes situated on the same site. Hollydale and Rowandale are owned and managed by Dalesview Partnership. Hollydale is currently registered to accommodate eight service users with a learning disability and who may also have a physical disability. The home primarily offers long-term care. The home stands in its own grounds and has open views to two sides. The building is a single storey purpose built establishment, with wide doorways and easy access throughout. The home consists of eight single bedrooms, which are all individually furnished, a bathroom and shower room, which have been specifically designed to provide a suitable environment for assisting clients with physical disabilities. There is also a large spacious lounge, dining/activity room and kitchen which clients may access with relevant supervision. In addition there is a laundry and office. There are communal gardens shared by the two homes. These have been landscaped to the front and side and offer a sensory area. There is also large patio to the rear. The home is situated in Clayton-le-Woods on the perimeter of a housing estate. There are a range of facilities including a supermarket, library, leisure centre, public houses and park within walking distance which the home accesses. Clayton-le-Woods is situated on the A6 which is the main road linking the city of Preston and the market town of Chorley. This means the service users also have access to the facilities offered in these towns. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over one day in September 2005 by one regulation inspector. The inspection involved observation of and discussion in respect of one of the service users who lived at the home and also discussion with and observation of the staff working there, an examination of records, policies and procedures and a tour of the premises. As part of the inspection, the inspector used “case tracking” as a means of assessing some of the National Minimum Standards. This process allowed the inspector to focus on one of the service users living at the home. All records relating to that individual are inspected along with the room occupied at the home. Where possible the service user is invited to discuss their experiences of living at the home. What the service does well:
The home had a thorough pre-admission assessment process in place, ensuring as far as possible that service users were compatible and that individual needs could be met. Care plans were detailed outlining individual support needs and preferred routines and therefore ensuring that staff were able to provide a safe and structured environment for service users. Person centred planning was also being introduced for each of the service users, allowing more focus to be placed on their individual needs and wishes. The home ensured that service users health care needs were assessed and addressed and staff were provided with information, giving them guidance as to the service users specific health needs and the action they should take in certain situations. This home was observed to receive guidance and support from a physiotherapist and a speech and language therapist. They had provided guidance for staff to ensure that service users received appropriate support. The home arranged appropriate home based and community based activities and encouraged and supported service users to participate in these. The individual interests of the service users were taken into account. The home was clean comfortably furnished and well maintained for the benefit of both service users and staff and was well placed to enable the service users to access local facilities. The home had a thorough staff recruitment procedure, protecting as far as possible the protection of service users. Staff took advantage of a variety of
Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 6 training opportunities and undertook all mandatory training. Training was linked to the support needs of the service users ensuring as far as possible that they received appropriate support. The home had achieved the Investors in People Award and a number of audits were undertaken regularly at the home to ensure that high standards of care were maintained. What has improved since the last inspection? 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. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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 Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The pre-admission process is in sufficient detail to ensure that a potential service users needs can be met. EVIDENCE: This standard could not be fully assessed at this inspection, as there had been no recent admissions to Hollydale. Previous inspections have shown that the pre-admission process is in sufficient detail to ensure that service users are compatible and that individual needs can be met. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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 The care plans for service users living at the home were very detailed outlining individual support needs. They ensured that staff were able to provide a safe and structured environment, and also work towards extending the service users range of experiences and options for the future. EVIDENCE: The file of one of the service users was examined and discussion took place with the service users key worker and a visiting speech and language therapist. The care plan contained lots of specific detail regarding the support needs of the service user including the service users preferred routines to be followed by staff at different times during the day. Discussion with the staff indicated that they had an understanding of the service users needs and the visiting speech and language therapist stated that support staff were very much aware of the service users communication needs. The care plan contained comprehensive guidance in respect of this. The home had commenced some person centred planning for the service user, which placed an emphasis on the individuals specific, needs and wishes. An outside health professional had facilitated the planning. An advocate had also been included in the planning group.
Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 10 Observation of the staff supporting the service user indicated that they used the care plan as a basis of the support they provided to the service user. A small booklet had been developed outlining the service users communication and support needs. This had been produced in a format that the service user could access more easily and it was planned that the booklet would be readily available for staff providing support. Comments were received from one professional associated with the home, which indicated that, in their opinion, the number of service users resident at the home was too large to facilitate the provision of homely person centred care. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 The home provided opportunities for service users to follow their interests and hobbies, promoting their involvement and inclusion in the local community. EVIDENCE: The file examined contained details of the service users interests and hobbies. The person centred planning process had resulted in the service users activities being reviewed, especially at the weekends and the recognition that more rest periods should be built into the routine. The staff also recognised that the service was able to make his own decisions about what he wanted to do and staff were observed to respond to his requests. The service user had his own transport and was able to access local facilities. The home had its own activities programme, which was developed with the needs of the service user in mind. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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): 19 The staff worked hard to ensure that the health needs of the service users were being met however additional work could be undertaken to ensure as far as possible that their health was being monitored and any concerns addressed. EVIDENCE: The home had good information available on the service users file giving staff guidance as to the service users specific health needs and the action they should take in certain situations. This home was observed to receive guidance and support from a physiotherapist and a speech and language therapist. They had provided guidance for staff to ensure that service user received appropriate support. The manager stated that they had a very good relationship with the GP. A comment card received from the GP indicated that he was satisfied with the overall care provided at the home. Information on the service users file provided evidence that the service user was supported to attend a variety of healthcare appointments. It was recommended that a health action plan be put in place for each of the service users to ensure as far as possible that the service users health care was assessed holistically and any concerns addressed. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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): 22 and 23 Information about the homes complaints procedure was not consistent leaving service users and staff with different guidance as to the different ways in which a complaint could be made. The homes policy, which deals with the protection of vulnerable adults, must be reviewed to ensure that the staff team are aware of the correct action that must be taken should an allegation of abuse be made. EVIDENCE: The homes service users guide contained a clear complaints policy, using illustrations to help service users understand. It was also available on audiotape, ensuring as far as possible that most service users would find the information accessible. No complaints had been made to the service since the last inspection. The information within the complaints policy contained slightly different information and this should be reviewed to make it clear that complaints can be made to the Commission for Social Care Inspection at any stage. Standard 23 was not fully assessed on this occasion although following discussion with the manager it became clear that the homes policy which deals with the protection of vulnerable adults must be reviewed to state that the Social Services Department must take the lead in any investigation into an allegation of abuse. While manager was fully aware of the correct procedure to follow it must be ensured that the rest of the staff team are made aware of the changes, which must be made to the policy and the action that is expected of them should they become aware of any allegations of abuse. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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 The home was clean and comfortably furnished, providing a safe and homely environment for both service users and staff. EVIDENCE: The home was bright, cheerful, clean and well furnished and provided a pleasant living and working environment. The premises were accessible to all service users, taking into account their use of wheelchairs and other specialist equipment. The home had access to local amenities and transport was available to support the service users to use these facilities. Any repairs required to the home were undertaken as necessary. The Environmental Health Department had last visited the home in 2003 and any recommendations had been acted upon. The Fire Service had been contacted earlier this year to provide advice about the alarm system. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 15 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): 34 and 35. The home had a thorough recruitment procedure in place, which ensured as far as possible the protection of the service users. The home provided a range of training opportunities for staff, which helped ensure that service users were appropriately met. EVIDENCE: The file of one member of staff was examined and the homes recruitment policy and practice was discussed with the manager. The file contained all of the necessary documentation and POVA checks had been undertaken on recently appointed members of staff. This indicated that the homes recruitment policy was thorough and ensured the protection of the service users as far as possible. The homes training records indicated that the staff were provided with good training opportunities and a member of staff confirmed this. The manager was keen to ensure that staff were provided with relevant training and at least five days training were provided each year. The home was continuing to work towards 50 of the care staff holding an NVQ level 2 or 3 in care. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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): 39 The home had a number of quality assurance checks in place to ensure that the care provided was appropriate to the service users needs. Some additional work could be undertaken to ensure that the needs and views of the service users are central to service provided by the home. EVIDENCE: The home had achieved the Investors in People Award which is a quality assurance system accredited by an outside body. The manager stated that the organisation was now working towards an additional quality assurance award, Investors in Care Excellence. There was documentary evidence in the home, which indicated that a number of audits were undertaken regularly at the home to ensure that high standards of care were maintained. Care plans were reviewed every six months to ensure support provided to service users was appropriate and the introduction of person centred planning was underway. Service user surveys were undertaken every six months to determine their views on the service provided. Key workers supported service users in this. Families had also been contacted, inviting them to comment on the service provided at the home. It was recommended that the results of the survey of
Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 17 families views, and the action the home take in response to them is made available, so that involved parties can be reassured that their interest and comments are valued. The views of professionals in the home should also be sought and the results of such a survey responded to appropriately Two of the service users living at the home had the support of independent advocates. It was recommended that were possible an independent advocate should be involved in at least all of service users reviews to ensure that support is appropriately provided. Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Hollydale Score X 2 X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000006000.V253527.R01.S.doc Version 5.0 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA22 YA23 Regulation 22 13(6) Requirement The registered person must establish a consistent complaints procedure. The registered person must amend the policy dealing with vulnerable adult procedures, ensuring that the correct guidance is provided and inform staff of the changes. Timescale for action 30/11/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA19 YA39 YA39 Good Practice Recommendations Health action plans should be developed for each of the service users. The results of surveys undertaken of families and involved professionals etc should be responded to appropriately. The involvement of advocates in the review process should be considered Hollydale DS0000006000.V253527.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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