Inspection on 06/05/05 for Hollyhead

This inspection was carried out on 6th May 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hollyhead 18/10/07

Hollyhead 19/01/07

Hollyhead 19/09/05

Hollyhead 13/12/04

Hollyhead 05/07/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Hollyhead 224 Shawfield Road Ash Aldershot GU12 6SQ Lead Inspector Catherine Campbell-Ace Unannounced 06 May 2005 12:30 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_v223659_060505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hollyhead Address 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 To be confirmed CRH Care Home 3 Category(ies) of LD Learning Disability, 3 registration, with number of places Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age range of the persons to be accommodated will be 30-50 years. Date of last inspection 13 December 2004 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 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_v223659_060505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection lasted 2 hours. The Registered Manager was on leave and the inspector was assisted by the Area Manager and three service users. Daily records, care plans, risk assessments and activities of daily living records were inspected and were clearly written to assist the service users in achieving their goals and aspirations. The service users are non - verbal, they were observed to have a close relationship with the carers, who used various communication aids to assist in the daily activities. The staff support them in cooking meals, choosing furniture and decorations for the home and helping clean their bedrooms and communal living areas. What the service does well: The service was very homely with a supportive staff team in place. The service users were observed to be very relaxed and free to make their own choices and have the freedom of the home and garden. The support afforded to the service users included opportunities to take part in a quality of life which includes shopping, swimming, going to the local pub, cinema, bowling and even a two week holiday to Crete planned for the end of May, accompanied by a carer from the home. It was observed that there are close bonds between the service users and staff The Manager is planning new furniture in the lounge, which will be decorated afterwards. The service users are included in choosing the decorations, and staff stated that they will take the service users out to choose the furniture. The care planning was exemplary, which included risk assessments for activities such as making a drink, bus travel and cooking, all of which were updated at regular intervals. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 6 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. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 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_v223659_060505 stage 4.doc Version 1.30 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) 1,2,3 A full assessment is made prior to service users admission, which includes input from multidisciplinary teams and up to date information, which is available to empower the service users and their advocates in the choice and suitability of the home. EVIDENCE: It was evidenced that a multidisciplinary team of Psychiatrists, Speech Therapists and Psychologists are included in the pre admission process, together with the person to be admitted and family or advocate. The care plans showed a full assessment of needs had taken place and it was evidenced that the home could meet these needs. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 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) 6,7,8,9, The service users were observed to be supported by staff, ensuring that they live as full a life as possible and were included in choosing furniture and decoration for the home. EVIDENCE: The care plans were evidenced and found to be comprehensive and a live document, as they were updated when appropriate and included personal goals and aspirations. The plans incorporated a yearly assessment together with the service user, speech therapist, psychologist, carers and family or advocate. The home must be commended on the high standard of the care plans. The care plans were observed to contain risk assessments of daily activities such as making a hot drink, cooking and going out on the bus. These forms included information about the level of risk, and what to do to reduce that risk. The service users are non-verbal. The care plans are made together with the service users, advocates or family members. It was observed that the care plans had been signed. The care staff used communication cards, pictures and individual communication boards to assist the service users in communicating Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 10 with the staff. The inspector saw one service user using a communication aid during the inspection. The staff stated that the service users took part in choosing the colours for the new kitchen, and were looking forward to going out to a furniture store to choose a new sofa for the lounge. They also said that the service users were going to choose the colour of the paint for the lounge. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,16,17 The home offers varied opportunities for the service users to make choices about their lifestyles. Service users are encouraged and supported to have a wide variety of social contacts and enhanced self worth and achievements. The goals set in the home to improve service users lifestyles are excellent. EVIDENCE: Each care plan evidenced, included the service users goals and aspirations, detailing what the service user wanted to do and achieve. The care plans included daily living skills, including how the service user made breakfast, and which foods were for breakfast i.e. Wheetabix or porridge. Target plans were evidenced and these were monitored regularly. The service users had been out for a drive on the morning of the inspection, and another was going swimming in the afternoon, accompanied by a staff member. The care plans stated that the service users have a varied and active life and are able to have aromatherapy massage, go bowling, go to the cinema, public house, and shopping. One of the service users has booked a Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 12 holiday to Crete at the end of May accompanied by a member of staff. Another has spent weekends away. It was evidenced that the service users take responsibility by choosing the activities they attend, helping around the home, and choosing furniture and paint for the home. The service users help shop for food and it was evidenced that they chose the food by the staff holding up pictures of what food they like to eat. The care plans stated that the service users could make drinks and help with cooking the food. The kitchen was newly refurbished with new equipment and flooring. The menu was evidenced and the service users receive a balanced varied diet. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 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 standard(s) 18,19,20,21 The home continues to offer individualised care to the service users to ensure that all their needs are met in a person centred way. EVIDENCE: Care plans included clear guidelines on any intervention of support each service user required with personal care. Physical and emotional needs of the service users were also detailed in the care plans and daily records. These included visits to dentist, doctor, behaviour charts and major incident forms. The homes medication system is followed and policies in place. No service user is self-medicating. It was evidenced that the home had addressed death and dying, as one service user had recently lost his mother. This was addressed sensitively and respectfully with the staff member showing pictures of this person’s mother, and talking about her to him. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 14 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) 22,23 The home operates in a manner, which includes the service users, advocates and family members. They are able to act for the non-verbal service users, and support them in their communication. EVIDENCE: Service users in this home are non - verbal. The care plans showed that they have family members and advocates who act for them. The staff stated that they know when a service user is unhappy as their behaviour changes. They then spend time with the service user trying to find the problem. Speech therapists are enlisted to aid communication. The home has a complaints policy. It was noted that there had not been any complaints since the last inspection. Staff have attended Protection of Vulnerable Adults training, and were aware, when asked, of the procedure if abuse occurred. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 15 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) 24,25,27,28,30 The home offers a homely, comfortable and safe environment. EVIDENCE: The home environment was clean and well maintained. The service users have chosen the colour schemes in their bedrooms, and a sense of ownership was noted. The staff stated that the lounge is going to be re decorated and the service users were going to choose the colour scheme and new furniture. The kitchen had recently been refurbished, which included new appliances. The services users help with the cooking and the staff said that they enjoyed the new equipment. The kitchen was clean and tidy, with food appropriately stored. Toilets and bathrooms were observed to be clean and tidy, provided sufficient privacy and met the service user’s needs. The service users could use the outside of the premises and one service user was observed to walk in and out of the house freely. A trampoline had been added to the area outside the side of the house and is used by the service users. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 16 Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36 The home employs a stable and efficient staff providing a competent quality of care to the service users. EVIDENCE: The staff team at Hollyhead are well supported by the Managers. It was evidenced that meetings were held to discuss the ongoing care needs of the service users. The staff are qualified in NVQ level 2 with one staff having almost completed NVQ Level 3. The target of 50 has been met. It was evidenced that other training courses comprised of: First Aid, Makaton, Food Hygiene, POVA, Antidiscrimination, Fire Safety, Health and Safety, Epilepsy awareness, Safe handling of medication. It was observed that all staff had their own training plan. Staff supervision records were seen, and staff were supervised formally every two months. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 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 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) 37, 38, 39,40, 41, 42, 43 The home offers a person centred service to the service users and the management of the home is efficient and effective. EVIDENCE: The homes policies and procedures were evidenced, and safeguarded the service users and promoted their independence. The Manager is soon to complete NVQ4 in Management. The home’s ethos, leadership and management were evidenced and it was observed that the service users lived a full and active life, inside the home, and out in the community. The frequent reviews of the service users goals and achievements showed that the staff monitored these goals and ensured that they were met. Policies and procedures were seen, and the record keeping was commendable. Risk Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 19 assessments for activities of daily living were in place and reviewed regularly and staff attended Health and Safety and Fire training. The Area Manager stated that the Company would absorb any costs if business was interrupted, and that staff had knowledge of accountability. She said that the service users would be given quality control questionnaires, assisted by keyworkers, families or advocates. Hollyhead H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hollyhead Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 H58_s13677_Hollyhead_v223659_060505 stage 4.doc Version 1.30 Page 21 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 Regulation Requirement Timescale for action 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_v223659_060505 stage 4.doc Version 1.30 Page 22 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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