Inspection on 22/05/08 for Hollyrood

This inspection was carried out on 22nd May 2008.

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

Other inspections for this house

Hollyrood 27/09/06

Hollyrood 06/01/06

Hollyrood 02/08/05

Hollyrood 23/02/05

Hollyrood 04/11/04

Hollyrood 02/10/03

Hollyrood 28/07/03

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Hollyrood Heath Road Coxheath Maidstone Kent ME17 4NP Lead Inspector Jenny McGookin Unannounced Inspection 22 & 30th May 2008 10:00 nd Hollyrood DS0000024090.V363681.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 Hollyrood DS0000024090.V363681.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. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollyrood Address Heath Road Coxheath Maidstone Kent ME17 4NP 01622 743185 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) Hollyrood@mcch.org.uk www.mcch.co.uk MCCH Society Ltd Miss Katherine Jane Reeves Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2006 Brief Description of the Service: Hollyrood is one of a group of small care homes managed by MCCH Society Ltd. It is a detached ex police house, which has been adapted to provide 24hour residential care for four ladies with learning disabilities. There are two bedrooms on the ground floor that are equipped with fully assisted en-suite bathrooms. The home has a large kitchen / dining area and a lounge. A further two bedrooms are situated on the first floor and these share a main bathroom equipped with a bath seat, toilet and washbasin. The staff sleepover room/ office is also based on the first floor. The home has ramps and grab rails at both the front and back garden areas and around the premises. Staff work on a roster system with one member of staff providing sleep in cover. A minimum of two staff are on duty between 9 am and 9 pm. The home is situated on the main road of Coxheath at the traffic light junction with the main A249 to Maidstone and Hastings. The home has good local amenities and shops in the village of Coxheath, and is on main bus routes into Maidstone town centre. Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service User Guide. The range of fees was not available at the time of this inspection. Fees do not cover personal items such as toiletries, clothes, magazines, leisure and social activities (though the fee does cover some staffing costs), extra furniture and fittings, the service users’ own possessions or holiday costs. The e-mail address for this home is: Hollyrood@mcch.org.uk Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which took the form of two site visits, one of which was unannounced and the second of which was prearranged. This inspection was intended to inform this year’s regulatory process; to review findings on the last inspection (September 2006) in respect of the day-to day running of the home; and to check compliance with recommendations made on that occasion. The inspection process took six hours overall, and involved meeting with the manager, two support workers and all three current service users. Consideration was also given to the Annual Quality Assurance Assessment submitted by the manager in November 2007. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical information about the service. The visit also involved an inspection of all four bedrooms and the communal areas, and the examination of a range of records. One service user’s files were selected for case tracking. Conversations with all three service users were possible and interactions between staff and the service users were observed during the day. Feedback questionnaires were issued by the inspector for distribution to service users and a range of other stakeholders. Two were submitted by service users with support from their key workers, but the others were not submitted in time to include all the responses in the first draft. Any responses received after the final publication of this report will, therefore, be assimilated into the Commission’s own intelligence, for future reference. What the service does well: The location of this home is judged suited for its stated purpose and the property itself is being maintained to an adequate standard. The home was tidy, clean and odour free. There are homely touches throughout The social, health and personal care needs of the service users are being addressed, and there is input from a range of healthcare professionals and other specialists as required. The ageing of the service users is being properly planned for. Service users are consulted on every aspect of their lives. This is done at resident meetings as well as through day to day interactions. They are supported with the development of daily living skills and have a choice of activities, on and off site. Care plans are properly underpinned with risk assessments, to keep people safe, and both systems are updated monthly to ensure their currency. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 6 The staff team is small and has been subject to shortfalls, but there is a long standing core group which has the qualifications, commitment and support to ensure a continuity of care. There is a good investment in staff training, and 60 are accredited to NVQ level 2 or above. What has improved since the last inspection? What they could do better: MCCH needs to evidence sustained compliance with its regulatory duty to carry out documented unannounced inspection visits at least once a month. The reader is advised that breach of this regulatory duty constitutes an offence. Contracts governing each placement require attention to obtain compliance with the provisions of the National Minimum Standards, and to be meaningful to the service users. Staffing levels must be maintained so that staff won’t have to lone-work on occasions, and service users won’t have to miss out on activities. Further improvements are planned to the Statement of Purpose with the introduction of more pictures and photographs. Club Connect, the MCCH day resource centre, will be closing in March 2008 which will mean Hollyrood will need to identify new activities and opportunities for its service users. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 7 Some matters are raised for attention in respect of the property and site. 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. The summary of this inspection report can be made available in other formats on request. Hollyrood DS0000024090.V363681.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 Hollyrood DS0000024090.V363681.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 5 This home is ensuring that prospective residents and their representatives benefit by having all the information they need to decide whether this home will meet their needs. Each placement is subject to contracts, which define the service the prospective resident will receive, but these need to be clearer and more accessible, if service users are to benefit from them. EVIDENCE: There have been no admissions for nine years i.e. before the provisions of the National Minimum Standards (hereafter referred to NMS) became applicable and their admissions were, therefore, not assessed against the NMS on this occasion. And there are currently no admissions in prospect. The last inspection (September 2007) judged the home’s Statement of Purpose and Service User Guide showed a good level of compliance with the provisions of the National Minimum standards. And the home’s AQAA told us that both documents had been further revised to provide information on new staff, and written and picture assisted information for prospective service Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 10 users and their families. Although revised documents were not submitted for assessment against the National Minimum Standards in time for inclusion in this report, we judged that the last inspection’s quality rating of “good”, should still stand. The home will need to evidence their issue to interested parties and whether other formats are warranted, or their non-provision will need to be justified by properly documented assessments. The AQAA told us that the home is looking at moving one of the current service users on to alternative accommodation, more suited to an assessment of her long term needs. We were told that person centered planning and joint assessments were being used to ensure that the move is correct for her. Regular visits were being planned, to her new home to help her with her decision and adjust. The placement of each of the current residents is funded by Kent County Council, which has its own contractual arrangements, which are outside the scope of this inspection. And each placement is also subject to other contractual documents in place, representing a tenancy agreement between the landlord (for whom MCCH acts as its agent), and the support MCCH undertakes to provide. Although we saw a copy of the MCCH support contract in the service user’s file we selected for inspection, as required by the last inspection, it was not in an accessible format, which could be meaningful to the service user, and it will require correction. It commits MCCH to the provision of advocacy and to the provision of lockable facilities and two bedroom chairs (none of which is currently the practice) when assessed against the provisions of this standard. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 6, 7, 8, 9, 10 Individuals benefit by being involved in decisions about the care and support they receive. EVIDENCE: The format of the person-centred care planning introduced since the last inspection should enable all aspects of the service users’ personal and health care, as well as their social care needs to be addressed. They are written in the 1st person, to help ensure the service users’ perspective is kept central and make good use of illustrations, to help service users identify with their provisions. One service user spent time with us, leafing through her care plan, explaining what each section represented and some of the key decisions she had been involved in making in respect of her health, activities of daily living (e.g. shopping, cleaning, meal preparation) and work experience. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 12 There was good evidence of regular reviews, and of contributions made by the service user and other interested health and social care professionals. This was judged an inclusive approach to care planning. And the plans are properly underpinned by a wide range of risk assessments covering each individual, their activities and environments (on and off site) to keep people safe, as well as guidelines, to ensure staff practice complies with agreed standards. Record keeping was judged systematic and open to inspection by anyone authorised to do so. The home’s arrangements for keeping confidential information secure against unauthorized access was judged satisfactory. Cabinets are lockable and computerised records are password protected. But only one of the bedrooms inspected had a lockable facility, for service users’ exclusive use. The reader is advised that this is required – non provision must be justified by properly documented risk assessment or “optout” consultation. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. 11, 12, 13, 14, 15, 16, 17 People who use services benefit by the support they have to make choices about their life style. And they are also supported to develop their life skills. EVIDENCE: Abilities, activities and personal preferences are properly identified in personcentred care plans, safeguarded by risk assessments and promoted by day-today consultation thereon. The service users have velcro boards in their bedrooms which are changed daily to help them to remember what they have planned for that day, though the plans are applied flexibly to take account of choice, and emerging ideas. In some cases, however, last minute changes have also had to be made for want of staffing. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 14 The AQAA gave a number of examples of daily activities: hydrotherapy, phsiotherapy, aromatherapy, bowling, theatre, cinema, pubs, clubs, social events (e.g. run by MCCH), family/friends visits and get togethers, a local social group run by the Salvation Army meetings, church, personal shopping, and personal banking i.e. activities not necessarily identifiable with or restricted to their learning disabilities. Club Connect, the MCCH day resource centre, will be closing in March 2008 which will mean Hollyrood will need to identify new activities and opportunities for its service users. We were told that one service user helps at the local church with flower arranging for special events such as harvest festival and Christmas. And another has been enjoying office work experience at MCCH head office twice a week, where she has a range of duties: collecting, sorting and stamping post, maintaining the office noticeboard, shredding paper, printing labels, helping with newsleterres and hospitality. We were shown pictures of her at work and the word processor which had been brought into her bedroom to help her identify with office equipment. She told us how she wanted to be a secretary one day and spent some time talking about what that meant for her. Clearly, the home was helping to make her aspirations as realisable as possible. There are open visiting arrangements. The home has a wall-mounted payphone box at one end of the entrance hall. Although this would not offer much privacy, there is also a mobile handset for the service users’ use. Family relationships are maintained and encouraged with letters, phonecalls and visits. Three service users went on holiday last year. One went to France to spend time with her brother and his family. Dietary needs and preferences are identified as part of the person-centred care planning process, and confirmed by day-to-day consultation. None of the service users requires a special diet but the AQAA told us they are encouraged to eat healthily. Large handled cutlery is available to one service user, if required. The service users were joined for lunch, which was judged well prepared and presented. The pace of the meal was unhurried and staff support was judged sensitive and supportive. The service users told us they liked the meals at this home. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 18, 19, 20, 21 The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The person-centred care planning process used by this home properly assesses the extent to which each service user can manage their own personal care, and their choice and control is actively promoted by staff. Daily records are maintained. The bedrooms in this home are all single occupancy to offer privacy and each service user is judged able to manage a bedroom door key, so that privacy can be assured. Observed practice was judged appropriately familiar and respectful. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 16 Two bedrooms have their own en-suite facilities and we judged there are enough communal toilet and personal care facilities (baths, showers, wash hand basins) to enable the service users to exercise some choice, though we have some concern about catering staff not having exclusive access to their own facilities. Staff are available on a 24 hour basis to assist the service users. The care planning process routinely addresses a range of standard healthcare needs e.g. GP, optician, chiropodist, physiotherapist, aromatherapists, and all contact and input is properly recorded so that emerging care needs can be tracked. The home also accesses care managers and we were told that one service user is being referred to a speech therapist. We were also told that since the last inspection, one service user had been discharged from their psychiatrist as she had made sufficiently good progress. As previously reported, service users have also been attending physiotherapy and hydrotherapy sessions and are supported with exercise programmes (devised by a physiotherapist) by staff. One told us proudly about her progress with an exercise bike. The home uses the monitored dosage system (MDS) and medication administration record (MAR) sheets. Recording standards were judged satisfactory – there were no apparent gaps or anomalies in the records seen. The manager showed us a copy of the home’s Royal Pharmaceutical Society Guidance to ensure its practice is compliant with best practice. Although its copy of The British National Formulary was dated 2005 (and therefore in need of updating) we were assured that staff would have ready access to information on medication on the Internet, to keep people safe. The home keeps its medication properly secured in a lockable wall-mounted cabinet. Feedback from staff and records confirm a satisfactory investment in staff training, with more training in prospect, and the home has an up to date list of signatures of staff authorised to administer medication. A pharmacist was scheduled to carry out an inspection of the arrangements the day before we carried out our inspection but had to cancel. Stock levels are checked by staff each day and then separately by the manager. There have been two medication errors since the last inspection (September 2006). Appropriate action was taken in each case, and both had been properly notified to us. There was good information (AQAA and anecdotal) about the ways in which the home has been monitoring and addressing the ageing needs of the service users. As previously reported, one service user will be moving to more appropriate accommodation. One service user had been referred for a wheelchair assessment. And another has had a commode installed in her bedroom for night time use, because of falls. The AQAA told us that the need for a slower pace of life is recognised in planning day-to-day activities. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 17 Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 22, 23 People who use the service are supported to express their concerns on a dayto-day basis. There is a complaints procedure in place but it is not being used. Service users are generally well protected from abuse, and have their rights protected. EVIDENCE: The home has a complaints procedure, as required, and a copy is in each bedroom, to facilitate access. We understand the home also has a more comprehensive pictorial complaints procedure in its Statement of Purpose, and that this is underpinned by MCCH’s policy and procedure. However, the absence of registered complaints is not judged a realistic reflection of communal living. The challenge for this home will, therefore, be to interpret expressions of dissatisfaction (e.g. in reviews, day to day interactions or group meetings) into recordable events, so that anyone authorised to inspect the records can properly judge compliance with this standard. One service user’s dissatisfaction with day services would be a notable example. There was no evidence of independent advocacy being used to support these service users, despite MCCH’s commitment to provide this in its support contract. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 19 Records confirm that service users’ financial transactions (e.g. benefits, deposits, withdrawals and outgoings) are being carefully recorded; and balance figures are being maintained, as evidence of probity. We understand that MCCH has a finance officer who carries out unannounced checks (at least annually) of each home’s accounts, to keep arrangements safeguarded. MCCH has a wide range of policies designed to safeguard its service users. Feedback and records confirm that staff receive training as part of a rolling programme, to keep people safe. In discussions, staff confirmed their commitment to challenge and report any instances of adult abuse, though they each went on to say that this had not been warranted in this home. Our own records confirm that there have been no adult protection alerts in respect of this home since at least September 2006. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some matters have been raised for attention, but the physical design and layout of the home generally enable services to live in safety, and encourages their independence. The property is adequately maintained and comfort EVIDENCE: The home’s location (in terms of access to community resources) and layout are judged generally suitable for its registered purpose, though its suitability for ageing service users is properly being kept under review by MCCH. There are handrails, a hoist, bath chairs and other aids to faciltate access by the service users as they grow older. But as previously reported, one service user is being supported to move to accommodation, which will suit her assessed needs. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 21 Measures are in place to keep the premises secure against unauthorised access or egress. The rear garden is landscaped to provide a very pleasant outlook and opportunities for relaxation, recreation and gardening, though the loss of a gardener had left it looking temporarily unkempt and possibly hazardous (concealed uneven surfaces). The home has a “No Smoking” policy. All areas of the home were inspected and found to be homely, comfortable and clean. Comfortable temperatures (though not all radiators had guards or low surface temperatures) and lighting levels were being maintained. Since the last inspection, the lounge has been redecorated and service users were involved in the choice of décor. There were homely touches throughout. The communal areas of this home are reasonably spacious, and there is a choice of communal areas (lounge and dining). The seating in the dining and lounge areas is domestic in style, but this is judged currently appropriate for the service users. Since the last inspection a new sofa has been installed. The kitchen is light, airy, clean and well maintained. Its external windows and door do not have fly screens when opened, nor is there an insectocutor, to prevent the infestation of insects. We were concerned that catering staff did not have a separate wash hand basin or a dedicated WC. In this home, the home’s washing machine is sited in the kitchen, and does not have a sluice cycle (incontinence is said to be an occasional issue). Although MCCH has taken the view that this is often how most domestic homes are set up, we do not think this is not good health and safety practice. All the bedrooms are single occupancy. All the bedrooms were inspected and judged well maintained and personalised. In terms of their furniture and fittings, they were, however, generally not fully compliant with all the provisions of the National Minimum Standards. The reader is advised that non-provision needs to be justified in each case (e.g. by properly documented risk assessments or “opt-out” consultation). Service users have a choice of bath, shower and WC facilities, though access could be difficult for service users using frames. Two bedrooms have there own en-suite facilities. The others have their own wash hand basin. All the maintenance records seen were up to date and systematically arranged. The storage of substances hazardous to health was judged secure. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in generally sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The waking / working day has been interpreted as 7.30am till 10.30pm, and visitors should normally expect to find two support workers and their line manager on duty (though she does occasionally work as the third person on site). At night there is invariably one member of staff, sleeping but on call. And there are wider on-call arrangements to keep people safe. This arrangement was in fact confirmed by feedback and observations during both site visits. There have, however, been times when we were told staff have been lone working because of funding constraints, though recruitment drives have since addressed this shortfall Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 23 There are no dedicated ancillary staff (e.g. cooks or cleaners). These tasks are covered by the staff responsible for direct care, and the service users are supported to carry out some domestic chores. Records indicate a sound level of training investment by MCCH in all the mandatory areas, to keep people safe, as well as some specialist input to meet the service users’ special needs. 60 of the permanent staff have accreditation to NVQ2 or above. Notwithstanding staffing shortfalls, Hollyrood has benefited from a longstanding core group of staff, which has worked flexibly to provide continuity of care. The rapport between the manager, staff team and service users is appropriately familiar, relaxed and respectful. Both support staff spoken to on this occasion confirmed that they had formal documented supervision from their line manager, which in both cases exceeds the National Minimum Standards in terms of frequency, and records indicate this is representative. This arrangement should ensure practice conforms to expected standards and does not become variable. The manager was said to be accessible and supportive. One member of staff told us “I noticed when I came here it’s extremely well managed and led. Very thorough with all the files. When I did my first sleepover I had the entire programme written out for me plus details about where everything was. I had no problems”. We understand that that recruitment is managed centrally by MCCH’s Human Resources department, which keeps the documentation at head office, though the manager is involved in interviews. Unit managers are then notified, by way of a checklist, which checks have been satisfactorily completed and of each individual’s start date. MCCH routinely carries out POVA 1st checks, CRB checks, and it normally requires two references. These records are subject to a separate inspection at MCCH’s head office by one of CSCI’s own managers at least once a year – the checklist documents on site appeared to account for almost all the checks we would expect to be carried out. Staff feedback confirmed a robust recruitment process. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The home can evidence that it has quality assurance systems. MCCH’s business management systems are not judged sufficiently effective. MCCH has not demonstrated a sustained awareness of its responsibilities regarding Standards, Regulations and Requirements. EVIDENCE: The Commission’s own registration processes have established that the manager, Katherine Reeves, had experience working with this client group as well as a range of relevant qualifications. And we were told that she has Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 25 obtained NVQ Level 4, the Registered Manager’s Award and Assessors accreditation. This is a home, which has been able to demonstrate good evidence of its inclusive approach to its service users. The service users have been clearly benefiting from access to a range of fulfilling activities as well as to mainstream community resources not immediately identifiable with or confined to their special needs. The home has its own Quality Assurance feedback process applied individually (we saw evidence of this on the file selected for case tracking) and through regular group meetings with service users. And there was documented evidence of feedback being systematically sought from relatives, most recently in April 2008. “I am made very welcome when I visit my sister. The staff are very friendly and very helpful and I am very happy with the way my sister is looked after” “We live in **** so we are not involved very often. We are kept informed. *** has been to stay with us twice and we visit when we go to England. **** always appears happy and content and we are satisfied she is well looked after” “We feel the staff are doing a wonderful job. Our niece has improved considerably since being at Hollyrood and much happier”. There was good evidence of business planning at a corporate and unit level over the past year. MCCH had set six corporate objectives for 2007/8, which then generated objectives for its West Kent operation. Each unit was then tasked to come up with measurements and outcomes, lead officers and targets to meet those objectives. Hollyrood’s action plan was in place. The registered proprietors of care homes have a regulatory duty to carry out their own documented unannounced inspection visits at least once a month. The last inspection (September 2006) reported that, following a lapse (since June 2006), these visits had been re-instated. But we found that there had been a further extensive lapse before these visits were re-instated again in November 2007, and there had been two months not accounted for since then. This effectively means the registered person had not been properly evidencing that checks were being made, to keep people safe. Breach of this regulatory duty constitutes an offence. A statutory Enforcement Notice may, therefore, become warranted, if these visits are not maintained. All the property maintenance recors seen were up to date and systematically arranged. Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 26 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 4 3 3 3 3 2 Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 YA43 Regulation 26 Requirement Visits by registered provider. The registered person shall ensure that there is full compliance with the provisions of this regulation. Breach is an offence. Timescale for action 31/07/08 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 YA1 Good Practice Recommendations It is recommended that the home have a checklist to evidence the issue of its Statement of Purpose, Service Use Guide and contract, and whether other languages or formats were warranted. The “Support contracts” with the home should be checked for compliance with the provisions of the National Minimum Standard. And they should be in an accessible format, which would be meaningful to the service users. 3 YA22 Complaints procedure. The challenge for this home will be to interpret expressions of dissatisfaction (e.g. in reviews, DS0000024090.V363681.R01.S.doc Version 5.2 Page 28 2 YA5 Hollyrood 4 5 6 YA24 YA24 YA25 day to day interactions or group meetings) into recordable events, so that anyone authorised to inspect the records can properly judge compliance with this standard. It is recommended that the rear garden should be regularly tended and its surfaces needed levelling Radiators should have guards or low surface temperatures • The provision of furniture and fittings in bedrooms should be checked against the National Minimum Standards and non-provision should be properly justified by documented risk assessment or “opt out” consultation. Kitchen. The following recommendations are made: • Washing machine should not be sited in the kitchen – and it should have a sluice cycle • Windows should have fly screens when opened or there should be an insectocutor. • There should be a separate wash hand basin with soap and paper towels. • There should be a dedicated WC for kitchen staff close to kitchen with wash basin, soap dispenser, paper towels or air dryer 7 YA30 Hollyrood DS0000024090.V363681.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 0845 015 2255 or 0191 233 3588 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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