Inspection on 27/09/06 for Hollyrood

This inspection was carried out on 27th September 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 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

Hollyrood 22/05/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Hollyrood Heath Road Coxheath Maidstone Kent ME17 4NP Lead Inspector Debbie Sullivan Unannounced Inspection 27th September 2006 09:20 Hollyrood DS0000024090.V306849.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.V306849.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.V306849.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) MCCH Society Limited Miss Katherine Jane Reeves Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 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. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report of the Key inspection of Hollyrood has been compiled using information gained during the unannounced site visit which lasted a little over five hours, the pre inspection questionnaire completed by the Registered manager, comment cards and survey forms received from service users, relatives and health and social care professionals and from discussion with staff and service users during the visit. The home currently has four service users who have all lived there for some years. The cost of the service is £323.01 per week. During the site visit, time was spent speaking with service users, the acting manager and care staff. A tour of the property took place and evidence was gained from reading documentation and records at the home. Due to the nature of the service, it is difficult to reliably incorporate the views of service users in this report. Therefore some judgements about quality of life and choices have been made by using information gained in discussion with service users and staff and information evidenced on records and other documentation. Comments made by service users on survey forms and during the site visit included, “ I go to fitness and swimming, I go to the pub and shopping, and like doing my puzzles and watching TV” “ I choose my meals every day” “I help do the cleaning” “I like it here” “I like the girls (i.e. staff)” A relative stated on a comment card that, “We are more than pleased with the care and attention given to our (relative)” A health/social care professional stated that, “My clients are doing well within this environment” Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective service users are able to access clear information about the home to enable them to make an informed choice. Assessment procedures are thorough and the home meets the needs of current service users. EVIDENCE: Comprehensive information on the service is available in written and pictorial formats to prospective service users and their families. No new service users have moved to the home for approximately eight years and there are currently no plans for any change in the group living at the home. Although no recent pre admission assessments had been undertaken, care plans showed that needs are very regularly reassessed using the person centred planning approach, and goals and aspirations are recorded as well as any changes in health or personal care needs. Care plans did not include contracts or a statement of terms and conditions, the acting manager undertook to establish if these were held at the organisation’s main office in Maidstone in respect of the service users. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The needs, goals and aspirations of service users are clearly recorded on care plans and regularly reviewed. Risks are assessed and minimised. Service users are involved in decisions about their lives and the home. Information is held safely and securely. EVIDENCE: Three of the four care plans were inspected, the plans were set out in a format easily accessible to service users with plenty of pictorial information. Clear indexing and personal written or signed contributions from service users were included in some sections. The information included evidence of regular reviews, goal planning, risk assessments, health and personal care needs and preferences, information on daily routines and activities and personal backgrounds. The plans were very thorough and up to date, in the case of one service user who had been experiencing some recent difficulties it was easy to track where these were recorded, other professionals had been consulted, and Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 10 action had been taken with the service user to change aspects of their life. This had resulted in the service user being more settled and having new opportunities. Care plans and other confidential records are kept securely and are accessible to service users at any time. Service users are involved in the daily running of the home; during the site visit one service user went out food shopping and helped with the daily chores. Each service user is supported with the cleaning of their rooms. Two of the service users now have limited mobility, so support is given appropriate to needs and abilities. Residents meetings are held regularly and are recorded and pictorial service user surveys are circulated. Completed surveys were on care plans. Risk assessments are reviewed as required and as part of the goal planning process, they are revised when needs or activities change. Service users are supported to be as independent as possible whilst risks are minimised. An example of this is the addition of a bell to a walking aid so that whilst the service user likes to be independent, staff can be called if assistance is needed to minimise the risk of falls. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 The quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users are able to participate in a wide range of social and recreational activities within the home and the community. Contact with friends and relatives are supported. The rights of service users are respected by staff. Daily choice of meals is offered and meals are healthy and nutritious. EVIDENCE: Service users have lists of daily activities in their rooms and activities and interests are well recorded on care plans. Each service user has a tailored individual programme that is geared to their interests, age and support needs. Due to their ages not all of the service users wish to participate in work related activities, but they are offered a wide choice of social and recreational activities in the home and community. These include swimming, bowling, clubs, events Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 12 and groups run by MCCH, a local social group run by the Salvation Army, exercise classes, day trips out, shopping and aromatherapy. The opportunity to attend church is offered and the local vicar visits the home. Each service user had been on holiday this year; holidays are taken separately or with another service user. One service user was looking forward to a planned trip to Euro Disney, and another spoke of visits to and from relatives. Staff support visits to relatives who are unable to travel to the home. Contact is maintained with friends and relatives via phone calls and letters and friendships outside of the house encouraged. Physiotherapy and hydrotherapy sessions are attended and three service users have individual exercise programmes devised by a physiotherapist displayed on bedroom walls, staff support service users with the programmes. One service user had become dissatisfied with a day opportunities service that they attended. Following review and consultation with other professionals due to this and other changes in needs, the service user is now being supported in pursuing a personal interest in office work and has started supported work experience once a week. This interest is also being encouraged in the home, the service user has been provided with a computer and other new equipment is to be purchased. Discussion with the acting manager, the service user and documentation showed that this support had substantially improved the quality of life of the service user, and that they had regained enthusiasm. This attention to detail in terms of meeting any changes in needs is reflected in the homes’ responses to mobility needs, any health changes and review of daily activities. Throughout the site visit staff were respectful towards service users and there was a good rapport between them. Service users had been consulted about their choice of midday meal that was freshly cooked; they said they liked the meals at the home. Healthy eating is promoted. Meals are served in the spacious kitchen/dining room and daily choices recorded. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The personal and healthcare needs of service users are well met and personal preferences are respected. The home has responded well to the changes in the health needs of service users. Medication policies and procedures are followed, updating of the list of staff administering medication would enhance good practice. EVIDENCE: Personal care preferences of service users are recorded on their care plans and any specialised needs, for example in relation to sight, mobility or hearing are clearly documented. Privacy and dignity are maintained when personal care is given, this has improved for one service user with the repair of their bathroom. The healthcare needs of the service users are well met and the home has contact with a range of health and other professionals including, chiropodists, physiotherapists, aromatherapists, care managers, dentists and GP’s. Changes Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 14 in physical or emotional needs are recognised, documented and referred to the appropriate professional. The service users currently at the home are becoming older. The service recognises this and has adapted accordingly to their changed needs. Medication storage and recording was inspected, organisational policies and procedures for administration of medication are in place and staff doing so have had medication training. Records had been kept correctly, the list of staff working at the home qualified to give medication needs updating so it does not include staff who have left. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users and their representatives have access to a complaints procedure and can feel confident that any concerns will be listened to and addressed. Service users are protected from abuse by the homes policies and procedures. EVIDENCE: The home has a complaints procedure that is available in written and pictorial format; a copy was displayed in each service users’ room. Due to the nature of the service, the use of a formal complaints procedure can be difficult for service users, so staff are aware of changes in the mood, demeanour or expression of service users that could indicate they are not happy. No complaints had been recorded since the last inspection, and one service user had stated on their survey form that would go to staff with any problem. Relatives and professionals can also advocate on the behalf of service users. Adult protection policies and procedures are in place; new staff had either received adult protection training or were due to attend courses. Recruitment procedures ensure that new staff are all CRB checked. There were no adult protection alerts in relation to the home as was the case at the last inspection. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users live in a comfortable, clean and well-maintained environment. Individual bedrooms are personalised and adapted to the needs of service users. Equipment to support and promote independence is in place throughout the home. EVIDENCE: The house is well decorated and furnished, well maintained, clean and homely. Since the last inspection one ground floor bedroom has been redecorated and refurbished and it’s en suite repaired and made into a walk in bathroom with a fixed hoist. This followed an occupational therapy assessment and improves the opportunities for privacy and independence for the service user. Bedrooms reflect the interests of service users and had been decorated to their choice of colour scheme, one service user’s room housed their exercise bike and another a computer. Equipment to aid and promote independence is Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 17 provided, two service users use walking aids. The two downstairs bedrooms have en suite facilities; the service users in upstairs rooms share a bathroom and toilet and have washbasins in their rooms. There are grab rails throughout the property and the large garden has rails and pathways so that service users can access it as independently as possible. The garden is well maintained and has a fishpond, barbeque area and patio and garden seating. The shared space available is in the kitchen/diner area and lounge; the lounge carpet is very stained and marked and needs replacing. The standard of cleanliness and hygiene was good throughout the home. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 18 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): The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from the support of a competent and well trained staff group. Staff are well supported and supervised. EVIDENCE: An agreement is in place that CSCI’s Provider Relationship Manager inspects staffing records centrally at least once a year; therefore standard 34 was not fully inspected on this occasion. The result of the first annual inspection was that recruitment and vetting documentation were in place and improvement could be made to recruitment documentation. There have been some staffing changes since the last inspection, the Registered manager is on a temporary secondment within the organisation and a senior support worker has recently been appointed acting manager. The acting manager has several years’ experience of working at the home and supervision and management experience. The registered manager keeps in close contact with the home and the acting manager and is available for advice Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 19 and support. Four new members of staff have started working at the home this year and are at various stages of training or probationary periods. Two members of staff are undertaking the NVQ 2 in care and subject to satisfactory probation periods two more hope to start. If there are any gaps on shifts existing staff or MCCH bank staff cover them. The acting manager is working on tracking the training of all staff members and monitoring the need for update training. MCCH has a thorough induction and training programme, although recruitment was not fully inspected a sample of staffing files read and staff spoken with evidenced that induction is good, staff do not work unsupervised until they are competent and confident and CRB checks had been completed. Staff spoken with confirmed that training opportunities are good and training is promoted. Supervision meetings take place bi monthly and are recorded and regular staff meetings are held. Staff spoken with felt well supported by immediate managers and MCCH. It was clear during the site visit that staff are well liked by the service users who are comfortable in looking to them for advice and support and in expressing any worries. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 20 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): 37,38,39,40,41,42 and 43. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is run in the best interests of service users and staff and the atmosphere is open and inclusive. The homes’ policies and procedures protect service users and staff. EVIDENCE: Hollyrood has a friendly and welcoming atmosphere in which service users feel comfortable to air their views and are included in decisions about the home. The temporary change of manager was very recent, so it was difficult to gauge if this had had any impact on the service users, however they were all very familiar with the acting manager and were happy to offer thoughts on the home in her presence and with her support. The service has a range of organisational and service specific policies and procedures; a number had been reviewed this year. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 21 All the records inspected were up to date and confidential records stored securely. Quality assurance questionnaires are circulated to service users and relatives, a sample of recently returned questionnaires read from relatives were complimentary about the service. Safe working practices are observed, equipment is serviced as required and the house is regularly checked for any maintenance or health and safety problems. Fridge and freezer temperatures are checked daily. The home has a valid insurance certificate. The last Regulation 26 report received by the Commission was for June 2006;MCCH has undergone a rearrangement of managers responsible for visits to each house, hence the gap. The acting manager advised visits are soon to be reinstated. Investment has been made in the property over the last year and since the last inspection, with the refurbishment of one bedroom and en-suite and the last inspection noted that the kitchen floor had been replaced. Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 3 4 3 5 2 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 3 3 3 3 Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 23 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. 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. 2. 3. Refer to Standard YA5 YA19 YA24 Good Practice Recommendations It is strongly recommended that service user contracts with the home be placed on care plans. It is strongly recommended that the list of staff that are qualified to administer medication be brought up to date. It is recommended that the lounge carpet be replaced as it is stained and marked. It is recommended that Regulation 26 visits to the home be reinstated by the organisation following realignment of responsibility for the visit, and reports be submitted to CSCI. 4. YA39 Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Hollyrood DS0000024090.V306849.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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