Inspection on 12/10/06 for Hollygrove

This inspection was carried out on 12th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollygrove 16/02/09

Hollygrove 04/02/08

Hollygrove 20/12/05

Hollygrove 01/08/05

Hollygrove 29/03/05

Hollygrove 15/07/04

Hollygrove 08/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Hollygrove 49 Roman Road Salisbury Wiltshire SP2 9BJ Lead Inspector Roy Gregory Key Unannounced Inspection 12th October 2006 10:00 Hollygrove DS0000028451.V309921.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 Hollygrove DS0000028451.V309921.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. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollygrove Address 49 Roman Road Salisbury Wiltshire SP2 9BJ 01722 415578 01722 415578 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) Turning Point Limited Ms Deborah Stone Care Home 9 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2) of places Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 7 service users with a Learning Disability at any one time No more than 2 service users with a Learning Disability, over 65 years of age at any one time. 20th December 2005 Date of last inspection Brief Description of the Service: Hollygrove is a purpose-built service, initially opened in 1996, providing care and accommodation for nine people with a learning disability, the majority of whom have a range of personal and communication needs. The home is one of a number of care homes and other social care projects operated by Turning Point, a national organisation, within the Salisbury area. The property is situated in a residential area of the city, a short drive or bus ride from the centre. Car parking is available at the property and in the street. Hollygrove is a two-storey building, with residents bedrooms on both floors. All bedrooms are single, have wash hand basins fitted and are close to toilets and bathrooms. Various aids and adaptations are provided for less mobile residents, including a stair lift. Communal space includes a large kitchen and dining area, a sitting room, and seating areas in the hallway and on the landing. There is also an attractive garden. Weekly fees payable in respect of current service users range between £1004 and £1036. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit for this inspection took place between 10:00 a.m. and 4:45 p.m. on Thursday 12th October 2006. The acting manager, Colin Alford, was available from 2:00 p.m. The inspector, Roy Gregory, met with most of the service users. The inspector joined service users and staff at the midday meal and observed social interactions in the sitting room and dining area. Additionally there were conversations with support staff on duty at the time of the visit. The inspector read three support plans in detail to compare observations of care with written records and plans. Other records consulted included those relevant to staff training and supervision, medication, health care and health and safety. All communal areas of the building were visited and three bedrooms were seen. It had been the intention to canvass the views and perceptions of relatives of the residents. However, the inspector was able to read the responses from the service’s own survey of relatives. These were so closely aligned with the same people’s written responses to the inspector at the time of the previous inspection, that such an exercise was considered superfluous on this occasion. None of the service users were currently receiving a service from an allocated care manager. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visit to the service and taking into account the views and experiences of people using the service. What the service does well: The routines of the home had a “family household” feel, a mix of spontaneity, inclusion of residents in essential tasks, planned individual activity and leisurely use of communal and personal facilities. Clearly an element in this style of care provision was the fact that many of the staff have worked several years at Hollygrove, resulting in sound working relationships with residents. Staff showed skills in communication with residents and included them routinely in conversations and decision-making. This also meant that staff were aware of changes in wellbeing, resulting in prompt referrals to medical attention and compliance with guidance from health professionals. When a person had been admitted to hospital, the home had supported their stay by 24-hour staffing. Records showed that on another occasion, the GP had seen hospital admission as possibly indicated, but preferred that the person remain with their familiar care regime in Hollygrove. There was much evidence of support to activities and community access, also of residents exercising choice. At the midday meal, all residents had different individually prepared meals, one a meal he had helped to prepare as a planned activity. Another resident chose to have his meal in a sitting area where he had got comfortable, rather than use the dining area. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 6 Sampling of care plans showed that three-monthly reviews were being maintained, and to a good standard. These involved the key worker, project worker and service user. Changes were recorded, along with the involvement of other agencies, leading to action points that would be further reviewed in three months time. Considerable efforts had been made to emphasise and encourage what service users could do and what they wanted to achieve. What has improved since the last inspection? What they could do better: Whilst overall the home provides a pleasant and homely environment, there had been no improvement to the kitchen. It was recommended at previous inspection that the kitchen should be assessed for state of repair, and identified shortfalls made good. Whilst it is understood that the provider has been affected by protracted negotiations about change of social landlord, this room continues to provide an unsatisfactory working environment for staff and needs extra vigilance to keep service users safe. It is therefore a requirement to produce a plan for upgrade. It is recommended that a plan for programmed redecoration of the home will help prevent other areas getting to a similar point. It is also recommended that there be a regular audit, say 3-monthly, of areas that can deteriorate and thus pose a risk of compromising infection control standards; as an example, a toilet seat was identified as needing immediate replacement. Where a resident is prescribed a medicine “as needed”, the way in which it is to be used must be detailed in a care plan, to be sure its use is always safe. Hollygrove DS0000028451.V309921.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. Hollygrove DS0000028451.V309921.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 Hollygrove DS0000028451.V309921.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (None of these standards was assessed at this inspection) Satisfactory provision for prospective admissions is in place. Quality in this outcome area is good. This judgement has been made using available evidence, excluding the visit to this service. EVIDENCE: The key standard no. 2 was not considered relevant at this inspection, as there have been no new admissions since 2003, and none were in prospect at this time. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 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, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Support plans link clearly to risk assessments, the inputs of external professionals and internal reviews based on experience. Residents are enabled to exercise choices and to make decisions. EVIDENCE: Sampling of care plans showed that three-monthly reviews were being maintained, and to a good standard. These involved the key worker, project worker and service user. Changes were recorded, along with the involvement of other agencies, leading to action points that would be further reviewed in three months time. It was also established that the local team for people with learning difficulties upheld full annual reviews, although with no residents having permanently allocated care managers, some staff saw these reviews as somewhat shallow. They also regretted that the previous year’s development of pictorial aids to reviews, and greater resident involvement in preparation for them, did not seem to be valued by care managers. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 11 There was very good cross-referencing between care plans and risk assessments, showing that considerable efforts had been made to emphasise and encourage what service users could do and what they wanted to achieve. Service user plans also paid good attention to individual communication needs. This was reflected in some very good examples of staff engaging with residents and ascertaining individual choices. It was evident that residents chose rising, eating and retiring times, and made use of different rooms and facilities as they wished. Over the longer term, they were encouraged via person centred planning and internal reviews to set an agenda for their lives. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 12 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, 13, 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 nature of working relationships between service users and staff, mean that residents have access to planned and spontaneous activities that fit their individual wishes and needs. These provide for access to the wider community, opportunities for individual development and maintenance of significant relationships. Good quality meals are served, taking account of individual needs. EVIDENCE: All residents had supported holidays during 2006, apart from one who had chosen not to do so, and one who had not been well enough. There was plentiful evidence of service users being enabled to exercise individual choices of community access, both to meet everyday shopping needs and for leisure. On the day of inspection, people were assisted to go out on foot, and by using the home’s large car. Two service users went out regularly with Turning Point outreach workers allocated to them. With the decline of external day resources Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 13 there were more service users at home during the day, and thus more emphasis on meeting activity needs. The routines of the home had a “family household” feel, a mix of spontaneity, inclusion of residents in essential tasks, planned individual activity and leisurely use of communal and personal facilities. Staff showed skills in communication with residents and included them routinely in conversations and decision-making. It was an evident strength of the service that relationships between residents and staff had developed over many years. Staff had recently decided in a meeting to re-allocate key worker responsibilities in order to give fresh impetus for residents. It was planned to adopt more of a team approach, so that for example individually planned activities would not be dependant on key worker availability, but allocated key workers would still ensure basic care needs were planned and upheld, and would arrange holidays with residents. Staff considered the adoption of a “person centred approach” in care provision had produced evident benefits for individuals. For example, a resident was enjoying regular family contact as a result of wishes and needs having been explored and pursued purposefully. At the midday meal, which the inspector joined, all service users had different individually prepared meals, mostly in the dining area of the kitchen, but one person choosing to remain where he was comfortable. One resident had a meal he had helped to prepare as a planned activity. Other examples of resident involvement in household management were support given to bed making and to laundry tasks, at times people chose for themselves. Care plans stressed the importance of self-determination in such areas of life. Residents were encouraged to take responsibility for helping to clear away after the meal, and to recognise each other’s needs. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 14 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 - 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff offer personal support that matches service users’ needs and recorded preferences. Healthcare needs are recorded and their management includes use of external consultation and guidance in order to identify and meet needs. There are good systems for management of medications, except use of “as needed” medications should be guided by individual care plans. EVIDENCE: Personal plans contained clear and up to date guidance on personal support needs. One person was currently in need of particular assistance with eating and drinking. They were given choice of how far that support was needed at any one time. A support worker described the guidance given by the person’s speech therapist and physiotherapist, which was detailed in the care plan and was clearly followed by staff. In assisting the taking of breakfast, a support worker maintained eye contact with the service user, and explained what they were doing, with reminders of the reasons for how things were done. Indicators such as clothing and skin care, combined with service users’ contentment, showed that residents were well cared for and supported in their own self-care. With regard to provision for health care, all appointments with Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 15 doctors and other health professionals, with their outcomes, were tracked by objective recording. When a person had been admitted to hospital, the home had supported their stay by 24-hour staffing. Documentation showed that on another occasion, the GP had seen hospital admission as possibly indicated, but preferred that the person remain with their familiar care regime in Hollygrove. When the inspector checked medication administration records, one recording error was found. It was established this had already been recognised by staff that morning, arrangements had been made to address it and staff had made sure the service user concerned had been given correct medication. A previous error, that had been notified as required to the Commission, had been used openly as a learning tool in a staff meeting. The home was getting a good support service from the supplying pharmacy, including training. Systems and storage for medications were satisfactory. For one person, a particular code was in use in medication records, to show compliance with how the usage of a medicine had been changed by the GP after initial prescription. But safe use of “as needed” medicines could be enhanced by care plans for their use, to show clearly in what circumstances they are to be used, their maximum dosage in 24 hours and how they are to be recorded – their use was not being consistently recorded on the reverse of the Medicines Administration Record charts, although could be cross-referenced to daily care records. All staff had recently received moving and handling training, which had highlighted mobility issues for a number of service users, for example in accessing vehicles. The outgoing manager had obtained some training materials about care of older people, which staff had found useful. The acting manager had reminded the provider of concerns within the home that issues of ageing are pertinent to a number of users, some of whom were now needing more support time, and were less able to sustain involvement in day activities. On the advice of the occupational therapist for the community team for people with learning difficulties, more suitable beds had been obtained for two service users. Another was beginning to receive support to using the home’s stair lift, on recognising that they may become reliant on it at some point. Both regular wheelchair users had pressure-relieving mattresses and received routine attention to pressure areas, and there was no history of pressure damage among the home’s users. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 16 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The provider and home have appropriate procedures in place to offer residents protection from harm, and to provide channels for receipt and consideration of complaints. EVIDENCE: No complaints had been received in the service since previous inspection. Information about the procedures for receipt and handling of complaints was readily available in the home, and the acting manager intended reminding relatives of them. In their bedrooms, all service users had pictorial information displayed, which invited them to share negative feelings with their key worker. There was a record of one service user’s use of a local advocacy service within the previous year. There was also readily available information about local safeguarding procedures for vulnerable adults. A person’s support plan contained guidance on a consistent response strategy to help them and staff manage a behaviour pattern that could be harmful to themselves or others. This was clearly based on consultation with a learning disability nurse and psychiatrist. Examples were seen during the visit of staff helping to guide behaviours, to help residents establish personal space, and sometimes to remind them of each other’s sensibilities, in line with care plan guidance. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 17 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, 25, 26, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home environment balances practicality, in terms of meeting resident needs, with homeliness, but the kitchen does not meet these criteria. Standards of hygiene are high, subject to control over replacement or making good of environmental factors before they pose any risk. EVIDENCE: Most of the building presented well, although several staff pointed out areas where some redecoration is beginning to be indicated by virtue of the wear and tear caused by mobility aids. A forward plan for systematic redecoration would help avoid a large body of work becoming necessary all at once. The top priority must be the kitchen. The inspector was surprised to see no improvement in this room since the previous inspection, when it was recommended that: The kitchen should be assessed for state of repair, and identified shortfalls made good. Staff described subsequent makeshift repairs, but the problems of poor quality surfaces and failing doors and drawers continue to compromise cleaning to infection control standards, and health and safety of staff working in the environment. Staff members also said increased Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 18 vigilance was necessary because some service users were attracted to drawers or cupboards that had no fronts. Good systems were in place for ensuring routine cleaning duties were carried out, with the result that all areas seen, including bathrooms, toilets and laundry, were clean to a high standard. There was an absence of hand drying facilities in toilets, but paper towel dispensers were on order. A toilet seat was presenting a hygiene risk. As well as replacing this, it is a recommendation that a routine hygiene audit be instituted, to identify such risks as they arise. The home benefits from a variety of pictures and other homely touches. Three personal rooms seen were cosy and individualised. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 19 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 - 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The staff group are highly committed to the care task, supported by good practice in recruitment, supervision and training. This results in high quality working relationships for service users. EVIDENCE: Unusually for Hollygrove, the home has experienced staff shortage in the past year as a result of long-term sickness and maternity leave. Consequently there had been some reliance on agency and Turning Point relief cover, although a good measure of consistency had been achieved in terms of actual temporary staff supplied. Most agency use had been to cover night duties. No new staff had been recruited, but currently two posts were being advertised. Rotas showed the home’s normal staffing provision of three during day shifts was maintained. Staff spoken to considered staffing was adequate to the tasks to be carried out, and confirmed numbers on duty were planned in accordance with the numbers of service users to be cared for, and associated support needed, including special events. Staff accepted and responded positively to the expectation that they would be first to be asked to cover vacant hours. Staff confirmed that individual supervision, and team meetings, had been sustained through the period of staff shortage, which by this time was easing. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 20 Examples of supervision and appraisal records showed these were provided to staff to a good standard. Colin Alford described sharing work that had been undertaken to help establish common supervisory practice among the senior staff. Training records showed clearly what individual staff had achieved, and due dates for renewals of mandatory courses. Turning Point’s schedule of training courses showed ready availability of training for staff to fit into. The majority of support staff have achieved NVQ in care to level 3. Recruitment of staff is backed by Turning Point’s human resources section, which promotes conformity with statutory safe recruitment practice. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Appropriate, tested provision has been made for continuing efficient management in the absence of the registered manager, although provider oversight by way of visits has lapsed. The views of service users and their supporters are obtained to inform development of the service. There are good in-house and organisational arrangements for upholding health and safety. EVIDENCE: Debbie Stone, the registered manager, advised the Commission in September 2006 that she was to be seconded to another Turning Point service for nine months, and this had commenced by the time of the inspection visit. Acting in her place was Colin Alford, who has undertaken this role in the past and had the confidence of the staff. An application for registration of Mr Alford is anticipated. He will need to be supported to work towards the Registered Managers Award. Meanwhile there was evidence on site and prior to the inspection visit of Ms Stone having ensured management systems, including Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 22 staff supervision, were up to date. Colin Alford also showed how Turning Point regional management ensured and facilitated the upkeep of such systems. Actual monitoring visits had not taken place for a few months, but a 2-day “peer inspection” was scheduled for November 2006, which was to concentrate on evidence of implementation of person centred approach work with residents. Health and safety matters were being audited on a quarterly basis, the format in use leading to remedial plans to ensure shortfalls were addressed. Whilst awaiting contract arrangements to be made for legionella testing, all water outlets were subject to weekly flushing to minimise risk of bacteria build-up. Records of monitoring fire precautions were well kept. A new fire risk assessment was needed, and the provider organisation may be expected to give guidance in line with the Regulatory Reform (Fire Safety) Order 2005. Further to requirement from the previous inspection, there had been a survey of relatives of all service users to assist quality assurance in the home. There had been just one negative comment, related to an individual care issue, which had been addressed. The inspector was able to view all responses. Many of them contained additional positive comments; one, for example, saw Hollygrove very much as their relative’s true home, whilst another considered it as “the right placement” for their relative. There was evidence that Turning Point was developing a wide-ranging quality assurance system for use in all their services. About half of service users were joining in occasional residents’ meetings, which looked at broad topics such as Christmas and holiday wishes and preparations. A meeting about summer activities had used a picture board to assist communication, and photos of different locations. A food survey had been conducted in a similar way. Records and staff comments showed the extent to which person centred planning had enabled service users to increase their say over preferences and the nature of service they wish to receive, their views then being reflected in care plans. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 23 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 3 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 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 2 3 X X 3 X Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA20 Regulation 13 (2) Requirement There must be a care plan in respect of any medication prescribed “p.r.n.” or selfadministered. The kitchen must be professionally assessed for functionality, and made good to modern standards. A plan for upgrade to be in place by date shown. The registered provider must ensure unannounced visits are made monthly in accordance with the regulation. Timescale for action 31/12/06 2. YA24 23 (2)(b) 31/01/07 3. YA38 26 (2) 31/12/06 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. 2. Refer to Standard YA24 YA30 Good Practice Recommendations Institute a plan for scheduled redecoration of the premises. Arrange a regular audit of areas presenting potential infection control risk, e.g. toilet seats, in order to identify DS0000028451.V309921.R01.S.doc Version 5.2 Page 25 Hollygrove 3. YA42 and resolve possible compromises to hygiene at an early stage. The provider should give guidance to assist the home to comply with the Regulatory Reform (Fire Safety) Order 2005, in drawing up a new fire risk assessment. Hollygrove DS0000028451.V309921.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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