CARE HOME ADULTS 18-65
Hollyhead 224 Shawfield Road Ash Aldershot Hampshire GU12 6SQ Lead Inspector
Catherine Campbell-Ace Unannounced 19 September 2005 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 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 Stationary 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. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Hollyhead Address Hollyhead, 224 Shawfield Road, Ash, Aldershot, Hampshire, GU12 6SQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01252 345161 Mr Paul Hewitt Mrs Helen Mary Jones CRH Care Home 3 Category(ies) of LD Learning disability, 3 registration, with number of places Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 3 The age/age range of the persons to be accommodated will be 30 - 55 years Date of last inspection 6-May-2005 Brief Description of the Service: Hollyhead is a large detached bungalow situated in the village of Ash and is close to local amenities and transport links. The registered home provides care, accommodation and facilities for up to three service users with learning disabilities. All service users take up single occupancy and have access to communal facilities, which comprises of a large lounge/dining area, domestic style kitchen, laundry/utility room and bathroom. To the rear and side of the building is a large secluded garden. There is parking for several vehicles to the front of the building. The home benefits from its own vehicle. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection lasted two and a half hours. The inspector was assisted by the Area Manager, Registered Manager and staff. Service users in this home are non - verbal. Service user’s care plans and administration of medication records were examined and staff were interviewed. Service users were observed to be well supported by caring staff, giving them choice and opportunities to take part in varied activities both in house and out in the community During the inspection an area of concern regarding safety was raised and an immediate requirement was given to attend to this issue. What the service does well: What has improved since the last inspection?
Since the last inspection barbecue equipment has been bought, and lights have been purchased for the lounge. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 6 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. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 standard(s) EVIDENCE: Standard 2 was assessed during the last inspection Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 standard(s) 8,9 The home encourages, supports and enables service users to live active and full lives with staff support where needed EVIDENCE: Care plans included clear daily living skills of housekeeping, personal care, and helping to make tea and coffee and taking a bath. Staff were at hand to support and offer supervision to any service user that needed help whilst being mindful of service user’s choice. Each service user has a care plan which includes daily activities, medication and risk assessments. Risk assessments were very well developed and include all actions taken to ensure the safety and choice of service users. Both care plans and risk assessments are updated regularly. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 10 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 standard(s) 14,15 The home encourages service users to have a wide variety of social contacts and enhances self worth and achievements made. EVIDENCE: Each care plan viewed included statements of achievements and goals. The statements detailed daily living skills, support in the community, long term goals, for example, emptying the bins and making the bed. The Area Manager said that service users were constantly having visitors to the home. Service users were included in staff celebrations such as weddings and parties. Service users are able to keep in contact with family by email, and the Registered Manager said that this has made a big difference for one service user whose sister lives in Australia. The manager said that if a service user does not want to have a visitor their behaviour becomes very negative, and the body language shows that they are not happy. The manager stated that service users go out into the community to college, adult education, staff functions, and the local shop keepers know the service
Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 11 users well. Service users are encouraged to participate in shopping, for example, they are supported in giving money to shop assistants in return for goods. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 standard(s) 18,20 The home offers individualised care to the service users to ensure that all their needs are met in a person centred way. The systems for administering medication are good. EVIDENCE: Care plans viewed contained clear guidelines on any intervention of support each service user required with personal care. Physical and emotional needs of service users were also detailed in the care plans and daily records, which included visits to the doctor, dentist, aromatherapist and reviews of care. The homes medication system is good, with policies and procedures in place. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 standard(s) EVIDENCE: These standards were assessed at the last inspection. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 standard(s) 24,30 The home offers a homely environment for service users; however, one hazardous area was identified during the inspection. EVIDENCE: The home’s environment is clean and homely and maintained by staff and service users. The manager stated that plans were in place to redecorate the lounge and purchase new carpets and sofas. The service users have been involved in choosing the colours of the paint. On viewing the premises, an unsafe area was identified where a vehicle had collided with the gates and gatepost creating a dangerous hazard. This area was made safe immediately. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Standard 35 was assessed at the last inspection. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Standards39 and 42 were assessed at the last inspection. Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 17 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 x x x x Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 1 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x 3 3 x x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Hollyhead Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 18 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. Standard 24 Regulation 23(2) (b) Requirement The entrance to the driveway must be made safe. Timescale for action Immediate 19/09/05 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. Refer to Standard Good Practice Recommendations Hollyhead H58 s13677 Hollyhead v246868 260805 Stage 2.doc Version 1.40 Page 19 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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