Inspection on 07/02/06 for Hollydale

This inspection was carried out on 7th February 2006.

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

Other inspections for this house

Hollydale 03/10/08

Hollydale 02/08/06

Hollydale 28/09/05

Hollydale 28/02/05

Hollydale 06/09/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Hollydale Back Lane Clayton Le Woods Lancashire PR6 7EU Lead Inspector Val Turley Unannounced Inspection 7th February 2006 09:30 Hollydale DS0000006000.V264698.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 Hollydale DS0000006000.V264698.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. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 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.V264698.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 September 2005 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.V264698.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 that took place over one day in February 2006 by one regulation inspector. The inspection took 5 hours. The inspection involved observation of the young adults 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. What the service does well: What has improved since the last inspection? At the last inspection it had been recommended that health action plans be developed for each of the service users. The documentation for these had been developed and it was planned that these would be completed. The homes complaints policy and procedure had been reviewed and it contained all of the detail as detailed in the National Minimum Standards. All of the documents in the home contained consistent information. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 6 One of the senior members of staff had recently qualified as a physical intervention trainer. She had an awareness of the processes that had to be followed should physical intervention be necessary and was able to provide advice and support to the staff team. Training in epilepsy awareness had been provided for the staff team. A decision had been made to produce a newsletter across the organisation and that this would include the outcome of any surveys and the actions taken in response to the survey. 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.V264698.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed at this inspection. EVIDENCE: Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Service users were encouraged and supported by staff and involved health professionals to make decisions and choices about their daily routines and to undertake any activities as safely as possible. EVIDENCE: The home had undertaken a great deal of work to encourage the service users to communicate their needs and wishes. The involvement of a speech and language therapist in this process had proved particularly beneficial. Communication strategies for each individual had been assessed and developed, enabling communication to be facilitated for each service user. Protocols were in place for each service user for different routines during the day with guidance for staff as to how service user could be encouraged and facilitated to make choices and decisions. Advocates were involved where a service user had no family involvement and information about the local advocacy service was available. The file of one service user was examined and this contained risk assessments for the activities that he was involved in. The risk assessments were reinforced by the protocols for his preferred routines. The physiotherapist involved in the home had developed any risk assessments relating to any Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 10 moving and handling. Activities were assessed to allow support staff to work positively with the service user and minimise the risks in the process. Hollydale DS0000006000.V264698.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): 15,16 and 17 The staff team respected the rights and responsibilities of the service users and supported them to make decisions and choices in their daily lives. The staff team would benefit from clear policy guidance and some training to ensure they have an understanding of how best to support service users in their personal relationships. The meals provided for were prepared with the health, preferences and dietary needs of the service users in mind. EVIDENCE: There was evidence that the home had good relationships with families and that service users were supported to maintain these. Staff were heard to discuss family visits and events with the service users. The service users had photographs of family members in their bedrooms. Visitors were welcomed to the home and families were encouraged to help personalise service users bedrooms. The homes policy, which dealt with service users personal, family and sexual relationships was limited in detail and guidance and as such must be fully reviewed. The staff team had not received any specific training in sexual and personal relationships, which would assist them in their work with the young adults they support. The manager was however fully aware of the Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 12 rights of service user in this respect. The service users had opportunities to meet people and make friends within the local community. The routines within the home were service user led with individuals being able to choose activities and make choices. One service user had chosen to have breakfast in bed on the day of the inspection. Service users were observed to be able to choose to spend time alone and guidance regarding this was included within care plans. An activity session was observed during the course of the inspection and staff were observed to interact with the service users appropriately. The service users were relaxed in the company of the staff and were able to communicate their needs to them. Keys were available for each of the bedrooms and staff were observed to be mindful of service users privacy and knock on bedroom doors before entering. Discussion with the manager and the cook plus an examination of menus and other records showed that a great deal of effort went into providing service users with their preferred food s and appropriate diets. The speech and language therapist had been very involved and had provided training in safe swallowing. A choice of food was available for service users and a record was kept of the food and fluid intake for each service user. A record of service users weights was also kept to help in the monitoring of the service users health. Any advice from the dietician was acted upon. Service users were encouraged to become involved in the preparation of meals wherever possible. The service users were able to eat their meals wherever they felt comfortable and a number of dining areas were available. Appropriate support was observed to be offered to service users at meal times and there were strategies in place to manage any challenging behaviour at meal times. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The support staff had a good knowledge of service users preferences and personal needs and provided support sensitively and in accordance with their wishes. Some additional work needs to be undertaken by the home to ensure that the health needs of the service users and the management of medication meets the required standard to protect both service users and support staff. EVIDENCE: Service users preferred routines were included within care plans and these provided clear guidance for the support staff. Choices were included within the routines and again guidance was provided to staff as to how these choices were to be offered. The home was well equipped with technical aids to allow personal care to be provided safely. The physiotherapist provided training in the use of this equipment. There was evidence that the equipment had been recently serviced. Additional support was provided by a number of health and social care professionals including the epilepsy nurse specialist and a community nurse. The manager ensured consistency and continuity of support through the support she provided to staff, good relationships with families and health professionals and ensuring that the service users communication strategies were facilitated. Standard 19 was partly assessed. At the last inspection it had been recommended that health action plans be developed for each of the service Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 14 users. The documentation for these had been developed and it was planned that these would be completed. The management of medication within the home was inspected. The community pharmacist had recently visited and had provided a positive report in respect of the homes management of medication. Only the senior staff at the home administered medication and they had received accredited training in this. Epilepsy training and training in the administration of rectal diazepam had been provided for the staff team in December 2005. It was recommended that competency checks be introduced for all staff who administer medication to ensure that best practice is maintained. The medication policy was in need of review, as the guidance in the policy did not match the practice adopted in the home. There was no indication on service users files that service users had consented to medication. It was required that some guidance be prepared for staff regarding the individual service users ability to consent or their mannerisms and routines when medication is being administered. This would help staff to make an informed decision as to whether a service user is consenting to or refusing medication. The medication administration records (MAR) were completed accurately and a record of all medication entering and leaving the home was maintained. There was guidance in place as to when any as required (PRN) medication should be administered. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 15 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 The home had a comprehensive policy and procedure in place to enable any complaints to be dealt with effectively. The homes policies and procedures in respect of the protection of vulnerable adults did not provide the correct guidance for staff, leaving service users in a position of risk. EVIDENCE: The homes complaints policy and procedure had been reviewed and it contained all of the detail as detailed in the National Minimum Standards. All of the documents in the home contained consistent information. At the previous inspection it was required that the homes policy dealing with Adult Protection issues should be reviewed and amended. Although some amendments had been made, the policy still gave incorrect information and guidance. The guidance for staff as to the action they should take if they became aware of an allegation of abuse was not easily accessed and was incorrect. One of the senior members of staff had recently qualified as a physical intervention trainer. She had an awareness of the processes that had to be followed should physical intervention be necessary and was able to provide advice and support to the staff team. The homes policy that dealt with physical intervention gave incorrect guidance and did not emphasise the need for a multi-disciplinary approach in these matters. This should be reviewed to safeguard the service users at the home should physical intervention ever be necessary. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 16 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): 30 The home was clean and hygienic and provided a pleasant and safe environment for both the young adults and support staff. EVIDENCE: The homes laundry was situated so that soiled articles did not have to be carried through any food areas. The laundry was shared with the adjacent home. It contained equipment that was adequate for the needs of the home. It was clean, well maintained, protective clothing was provided and an infection control policy was in place which gave guidance to staff on how to reduce the risk cross infection. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 17 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): 32 The staff team was well motivated, understanding of and attentive to the needs of the service users. EVIDENCE: A number of staff were observed supporting a number of service users to participate in an activity group and also at lunchtime. The support staff were observed to be attentive to the needs of the service users and also demonstrated that they had an understanding of their means of communication. There was an understanding of any anticipated behaviour and there were strategies recorded within the care plans to help manage these. The home had good relationships with health and social care professionals and sought advice from them appropriately. The home should continue to work towards having 50 of its work force achieve a relevant qualification in care with a view to improving the quality and effectiveness of the support provided to service users. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 18 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 and 42 The home was well run and managed safely with staff having received appropriate training to maintain the health, safety and welfare of the service users. EVIDENCE: The registered manager had the relevant qualification and experience to run the home well. She was motivated and enthusiastic in her approach and was keen to ensure that the home met the Care Home Regulations and standards. She had undertaken a range of mandatory training and some additional training, including epilepsy awareness and a safe swallowing course. The registered manager ensured that the home was run with the health, safety and welfare of the staff in mind. The staff team had all undertaken training in safe working practices and refresher training was provided. Fire equipment was serviced on an annual basis and annual training was provided. The equipment and systems within the home had all been serviced at appropriate intervals and the documentation in respect of these checks was in place. Accidents and incidents occurring in the home were all recorded and reported were necessary. It was recommended that a system to monitoring these be introduced to help identify any emerging patterns. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 19 Standard 39 was partly assessed. At the previous inspection it had been recommended that the results of surveys undertaken of families and involved professionals etc should be responded to appropriately. The manager stated that this was being addressed and that the intention was to produce a newsletter across the organisation, which would include the outcome of any surveys and the actions taken in response to the survey. Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 20 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Hollydale DS0000006000.V264698.R01.S.doc Version 5.1 Page 21 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. 2. Standard YA15 YA15 Regulation Requirement Timescale for action 30/09/06 30/04/06 3 YA20 4 YA20 5. YA23 18(1)(a)(c)(i) Staff should receive training in sexual and personal relationships. 12(4) The homes policy regarding service users personal, family and sexual relationships must be reviewed. 13(2) The registered person must ensure that the medication polices and procedures are reviewed. 13(2) Guidance regarding the service users consent to medication must be developed for each service user. 13(6) 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 of 30/11/05 not met). A copy of the amended policy must be forwarded to the Commission for Social Care Inspection. 13(6)(7)(8) The homes policy dealing with physical intervention must be reviewed and a copy of the DS0000006000.V264698.R01.S.doc 31/03/06 31/03/06 30/03/06 6. YA23 30/03/06 Hollydale Version 5.1 Page 22 amended policy forwarded to the Commission for Social Care Inspection. 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. 4. Refer to Standard YA19 YA20 YA32 YA42 Good Practice Recommendations Health action plans should be developed for each of the service users. Competency checks should be introduced for staff in the administration of medication. The home should continue to work towards having 50 of its work force achieve a relevant qualification in care. A system of monitoring accidents and incidents in the home should be introduced. 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