Inspection on 08/12/05 for Holmbury Dene

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmbury Dene 08/08/08

Holmbury Dene 08/10/07

Holmbury Dene 18/05/06

Holmbury Dene 29/04/05

Holmbury Dene 22/12/04

Holmbury Dene 02/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Holmbury Dene 2 Lawrie Park Road Sydenham London SE26 6DN Lead Inspector Ornella Cavuoto Unannounced Inspection 8th December 2005 10:00 Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 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 Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 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. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holmbury Dene Address 2 Lawrie Park Road Sydenham London SE26 6DN 0208 7787700 0208 7789437 ask.providenceproject.org.uk 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) Providence Project Mrs Juliette Anne Hagan Care Home 10 Category(ies) of Learning disability (0) registration, with number of places Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 10 persons with a learning diability of whom up to 3 may also have a physical disability Date of last inspection Brief Description of the Service: Holmbury Dene provides care for up to 10 people with learning disabilities, up to three of who may have a physical disability. The support offered includes mental health and management of challenging needs. The home is staffed on a 24-hour basis, consisting of a manager, two assistant managers and full and part time support workers. The staff levels vary depending on the number of service users staying at the home at any one time and the level of their needs. The home provides respite care for service users who live in the community with carers and for service users awaiting a more permanent placement. The home is also the emergency placement and assessment centre for people with learning disabilities in Lewisham. It is a large, two and a half storey building close to Sydenham train station and local shops and services. The area is also well serviced by buses to central and south London. There is accessible off road car parking space for up to seven cars to the front and side of the building. The garden is accessible from the dining room. The ground floor is wheelchair accessible consisting of four single bedrooms, a reasonable sized kitchen, a mid –sized dining room, a large lounge looking onto the front of the building, one fully accessible shower room/toilet, one fully accessible bathroom and the staff sleepover room. The first floor contains three single bedrooms, two bathrooms /toilets, a lounge area and the staff room. There is also a self-contained flat on the first floor currently not used for accommodation. The second floor has a room used for volunteers. There were four service user vacancies at the time of the inspection. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the majority of which was carried out over one day although an additional visit was required to complete the inspection due to certain information not being accessible on the day of the inspection as the registered manager was off sick on the day the inspection took place. As part of the inspection two members of staff were spoken to including the deputy manager who assisted with the inspection process. In addition, two service users were spoken to and also a relative. Other inspection methods included a partial tour of the premises and inspection of care records. What the service does well: What has improved since the last inspection? The home has addressed the issue of addressing individual communication needs within service user assessments and there are detailed guidelines outlining the communication needs of service users. Some work has been done to ensure that service users are able to learn practical life skills but this needs to be improved with the work carried out with service users in this area being more accurately reflected within service user plans. Also, although service users are becoming more involved in the day to day running of the home further work needs to be done to enable them to be able to do more. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 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 Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 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 & 5. The Statement of Purpose has been revised but contains information which is not accurate and the format is not accessible to service users. There is evidence that service users needs are being assessed prior to being admitted to the home. Not all service users have a written contract or statement of terms and conditions with the home. EVIDENCE: A copy of the home’s Statement of Purpose was seen which was updated in November 2005. Although, this contains all the information required by regulation specific information in relation to the present registered manager of the home was inaccurate and needs to be changed. Also, the Statement of Purpose was not available in a format that would be accessible to service users. Subject to a requirement. A copy of the service user guide was not inspected on this occasion as at the last inspection this was seen and one and had been produced in an accessible format using “Widget ” picture graphics. A sample of service user plans were looked at and there was evidence of core assessments carried out by the local authority on service users files as well as the home’s own assessment. Subject to a previous requirement that assessments carried out by the home do not always comprehensively include all service users individual communication needs this has been met. There was Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 9 evidence that service users individual communication needs have been addressed with detailed guidelines being in place within the service user plan. Apart from one service user who lives at the home on a permanent basis none of the service users have been issued with a contract outlining the terms and conditions of their stay within the home. It is important that the home ensures that all service users are in possession of a contract that specifies details of the room they are to occupy, shared facilities to which they have access and fees to be paid. Subject to requirement from a previous inspection this is to be restated in this report. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 Service users’ plans are generated from local authority assessments but information was not easily accessible and they did not clearly reflect changing needs and personal goals. Service users make decisions about their lives with assistance as needed. Although improvements have been made there is still insufficient evidence that service users are consulted on, and participate in, all aspects of life in the home. There was little evidence of service users being supported to take risks and some service users did not have a risk assessment in place. EVIDENCE: Service user plans for all six-service users who are presently staying at the home were examined. The majority of the plans looked at included detailed guidelines which address how support is to be provided including triggers to and how to manage difficult and challenging behaviour. For some service users, plans included a detailed timetable of activities as part of the therapeutic support to be provided to service users that had been completed by the Challenging Needs Service. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 11 Evidence that service user plans had been reviewed was limited with only two including any information to demonstrate that reviews had been recently held. It was reported that multi disciplinary reviews are carried out every six months with service users and family members are invited to attend. However, they are not generally held at the home but at the day centres or at the main council offices. Staff from the home are not always invited to attend reviews particularly for short stay service users unless there is an identified problem although, it was reported that a copy of the review should be sent to the home. It is important as part of service users overall care that the home ensures they are kept informed of any changes in the needs of those service users who attend the home. Therefore, where possible staff should attend reviews or at least ensure they receive a copy of the review and this is kept on file. Subject to a requirement. In addition, apart from one service user where a relative had signed part of the service user plan there was no evidence to indicate that service users or their relatives or representatives are fully involved in the drawing up of plans and risk assessments. Subject to a requirement. Overall the service user plans are not easy to follow and generally do not demonstrate that a person centred approach is used to address service users needs. The information in relation to service users is very detailed making key information less easy to find, does not clearly reflect their changing needs and personal goals and may prove difficult for service users to understand. It is also difficult to identify the different periods that service users have stayed at the home particularly for those who attend the home on respite. There is an “End of Stay Report” but this is not being implemented. In addition, a lot of the information contained in the files needs to be updated and old information archived. Subject to recommendations. Subject to previous requirements the home has still not fully implemented a key worker system which causes problems in following through on agreed plans and effectively contributing to reviews. It can also leave service users lacking in focused support to achieve their personal aims for achievement and involvement. To be restated as a requirement in this report. Service users have been assisted to access support from advocacy services to assist them with making their own decisions. It was also reported that service users are supported to contribute to decisions made in the review process although there was limited evidence to support this. It was reported that the home introduced monthly service user meetings four months ago as a way of offering service users an opportunity to participate in the day-to-day running of the home. However, only the minutes of the meeting held in October were available for inspection. These did indicate that service users were encouraged to give their views on various aspects of the running of the home including the planning of activities. Also, one service user Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 12 spoken to confirmed that they had been involved in sitting on the panel for the recruitment of staff. Yet, other areas such as involving service users in policy review and providing service users with information in suitable and accessible formats remain underdeveloped. Subject to previous requirements this has been partially met and therefore is to be restated in this report. Risk assessments for service users were generally inadequate. Of those service user plans looked at some had a risk assessment in place but they were not up to date and there was no evidence of them being reviewed. One service user had a comprehensive risk assessment in relation to attending the day centre that had been completed with input from the Challenging Needs Service. Other service users plans did not include any evidence of a risk assessment. For example, one service user who has a tendency to abscond although there were general missing person guidelines on file a risk assessment had not been completed specific to the service users needs and to support staff on how to manage this situation. Subject to a requirement. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,14 &16 The home needs to provide more evidence that service users are being given opportunities for personal development. Service users are supported to become part of and participate in the local community. Although service users engage in appropriate leisure activities, the home needs to improve on how activities are planned particularly for individual service users. Service users rights are respected and responsibilities recognised in their daily lives. EVIDENCE: It was reported that service users are encouraged to learn and use practical life skills and social skills within the home such as getting them involved in preparing meals, tidying their room, answering the telephone amongst others. One service user when asked about what they did around the home said “ I prepare stuff” referring to helping with meals. It was also reported that service users are offered specialist interventions and opportunities by trained staff to address issues presented by their disabilities Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 14 and behaviour and that one service user was referred for bereavement counselling although did not engage. In relation, to spiritual needs one service user attends church on a regular basis. However, although there was some evidence that engaging service users to do household chores was discussed at the service user meeting other ways of supporting individual service users to learn and develop skills was not clearly evident within service user plans. “The End of Stay Report” requires staff to write an assessment on the level of service users practical, social and food skills but as previously mentioned this is not currently being used by the home. Subject to a requirement. Service users are supported to become part of and participate in the local community. A number of the service users attend local day centres. One service user spoken to reported how they went to the cinema with one of the other service users at the weekend. Also, on the day of the inspection some of the service users went out for a meal locally whilst another service user was going out to the pub and then for a curry. It was evident that service users do have access to and choose from a range of appropriate leisure activities and service users individual interests and hobbies are recorded within service user plans. A review for one service user discussed plans for a holiday to Ireland. However, subject to a previous recommendation that individual needs in this area are more systematically planned on a weekly and daily basis and systems for recording and monitoring activities which are in place, need to be used more effectively are still not being addressed. Therefore, this is to be restated as a recommendation in this report. Staff were observed interacting with service users on the day of the inspection with warmth and respect and it was evident that they are very familiar with service users needs. It was also observed that service users exercise a lot of individual choice in terms of their daily routines and could choose to be alone and spend time in their room or join in activities with the other service users if they wish. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 &19 Service users receive personal support in the way they require and although preferences were stated it was not presented in a format that service users could easily understand. Service users’ physical and emotional health needs are comprehensively met. EVIDENCE: All service user plans contain very detailed guidelines on all aspects of personal support and care required by service users including personal preferences around personal care, eating and drinking preferences, individual communication needs, mobility needs and managing behaviour presented by service users. However, as mentioned previously the information presented in service user plans is in a format that would prove difficult for service users to understand and they would benefit from a more person centred approach being used. See recommendations made in relation to standard 6. It was clearly evident that service users physical and emotional needs are being well met with regular liaison with a range of healthcare professionals including mental health teams, physiotherapists, G.P’s, speech therapists, district nurses, dentists, chiropodists amongst others. All appointments relating to service users health needs are recorded on a Medical Report form. In addition in relation to service users individual health needs there was evidence of monitoring of pressure areas, fluid intake and an epilepsy monitoring form. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Although, the home has a robust policy and procedures in place with regards to adult protection not all staff are familiar with these and neither have all staff had training in adult protection. EVIDENCE: The home has a very robust policy and procedures in place with regards to adult protection and includes a copy of Lewisham’s Adult Protection Procedures that are very comprehensive. Although, one staff member spoken to had had training in adult protection and had some knowledge of adult abuse and what to do in a situation where abuse was suspected they acknowledged that they had not read the homes policy and procedures. In addition, the manager reported that not all staff as yet have received training in this area. Subject to a requirement. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28& 30. Service users live in a homely, safe and comfortable environment. Service users’ bedrooms suit their needs and lifestyles and promote their independence. Shared spaces complement and supplement service users’ individual rooms. The home is clean and hygienic. EVIDENCE: The home is very spacious, well decorated and maintained and is suitable for its stated purpose. Furnishings and fittings are of a good quality and domestic in character. The home is wheelchair accessible on the ground floor and access to the building for wheelchair users is via the dining room that also provides access to the garden. It was reported that the home has looked into building a ramp at the front of the building but this was found not to be possible. A requirement has been stated at the last three inspections that the registered manager must submit details to CSCI on how the home intends to meet the requirements of the Disabilities Discrimination Act 1995 Part 3. This is not to be restated as a requirement in this report. Service user bedrooms are of a good size and are sufficient to meet individual needs and lifestyles. Furthermore bedrooms that were viewed were furnished to required standards. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 18 The home has a range of comfortable, safe and accessible communal spaces with two lounges /dining areas on the ground floor one of which is used as a quiet space and a room upstairs that is also used as a quiet space for service users. The kitchen is of a medium size and domestic in nature and there is a garden that is small but attractive. The home was clean, hygienic and free from offensive odours. The home has adequate laundry facilities. The home had adequate policy and procedures for control of infection. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33&36 Although service users are supported by competent staff they are not all NVQ qualified. Staff levels fluctuate depending on the number of service users staying at the home. Staff are not presently receiving regular supervision. EVIDENCE: The home presently has four staff vacancies. The staff team presently consists of a manager, two assistant managers, three full time support workers and seven part time support workers. Apparently, there was a recruitment drive carried out by the organisation recently but none of the staff employed were allocated to Holmbury Dene. As a consequence this has posed problems with maintaining staff that are qualified at appropriate NVQ Levels. At present although there are staff completing NVQs in Level 2 and Level 3 and two of the staff team are due to start the NVQ Level 3, 50 of the staff team will not have achieved a NVQ qualification by the end of 2005 as is required or will be working towards one. The organisation had requested that NVQ training requirements should be related to the whole organisation and not individual registered care homes but it has been confirmed that NVQ training requirements must be related to each individual home. Subject to a previous requirement this is to be restated as a requirement in this report. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 20 All staff are supported to the Disability Award Framework (DAF) (previously the Learning Disability Award Framework LDAF) that can be used towards achieving the NVQ Level 2. In addition, evidence was seen that staff are placed on regular training courses some of which are provided by Lewisham Partnership. In respect to service users being supported by an effective staff team a previous requirement was made that the manager must define minimum staffing levels for the home to ensure staff numbers and skill mix effectively meet service users needs. The home is registered to support up to 10 service users but regularly only has four – six service users staying at the home at any one time. Consequently, the home ‘s management will regularly review staffing levels and depending on service user levels and also service user needs, as some require two to one support or one to one support will ensure additional staff are placed on the rota. Also during the day many of the service users attend local day centres. The issue of staffing was discussed at length with the registered manager who stated that it was difficult to define a baseline for staffing levels as the needs and level of service users are constantly changing given the nature of the service. At the previous inspection it was stated that there should be a minimum of four support staff that are experienced and have been trained to NVQ Level 2. As mentioned the home has not achieved the requirement regarding NVQ qualifications. In respect to staff numbers the manager reported that there would always be at least one-two support workers based at the home at all times apart from one of the management staff and that the rota is always arranged to ensure adequate staff cover in respect to planned admissions. The home does use agency staff in cases of staff sickness or where emergency situations arise and additional staff are required but it was reported that generally only agency staff who are familiar with the home and service users are used. As the manager has not as yet submitted this information to CSCI this requirement remains unmet and is to be restated in this report. Staff meetings are held on a monthly –two monthly basis. Minutes of meetings were seen. These indicated that a good range of topics are discussed including issues relating to service users, staffing issues and general issues relating to the day to day running of the home. In respect to standard 34 recruitment records are not kept at the home but at Head Office. Therefore this standard could not be fully inspected and arrangements will be arranged to examine these at a later date. Although, evidence was seen that indicates staff are receiving supervision and a good range of topics are discussed including service user issues, key worker role, training and development this is not being carried out regularly. The manager reported that the assistant managers have now been delegated supervisory duties and hopefully this will ensure that staff receive supervision more regularly. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 21 Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 &42. The home is generally well run but the registered manager is still to attain the necessary qualifications to ensure the home and staff team are managed effectively. The manager must also ensure that all licences and certificates required by regulation be displayed within the home at all times. Service users benefit from the ethos, leadership and management approach of the home. Adequate systems are not in place to seek service users views on the management of the home. The health, safety and welfare of service users are not being presently being thoroughly promoted and protected. EVIDENCE: The present registered manager has experience in managing services and working with adults with disabilities. A previous requirement was that the manager must achieve the NVQ Level 4 in Management and Care; although the manager has started the course it will not be completed until the middle of 2006. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 23 There was evidence to indicate that the present manager has developed a positive and inclusive ethos within the home with feedback from staff confirming that the manager is very approachable, supportive and does encourage an exchange of ideas and contributions from staff. Overall the home is well run. However, it was noted on the day of the inspection that the registration certificate was not on display. This constitutes a breach of the Care Standards Act 2000. It is the responsibility of the registered manager to ensure all certificates and licences are obtained and displayed. Therefore, this is stated as a requirement in this report. There has been a requirement from the last two inspections regarding ensuring appropriate quality assurance tools and systems are in place. It was reported that the organisation has developed a quality assurance strategy that includes ensuring service users views are sought through service user review meetings and other methods. However, this was not available for inspection. Also, there was no evidence available that the views of all service users including those that stay at the home for shorter periods, relatives and other stakeholders involved in the service have been sought through customer satisfaction questionnaires. This is important as part of self-monitoring to look at how the service can be improved and developed. This has yet to be completed and therefore is to be restated as a requirement in this report. The home does have a health and safety policy in place but various aspects of health and safety practices were evidenced as not being followed by the staff. For example, although there was a risk assessment in place regarding hazardous substances and these are stored safely being kept in a locked cupboard the key was left in the lock potentially giving access to service users. A comprehensive environment and fire safety risk assessment was not available for inspection. Also, in respect to fire safety it was noted that call points had not been carried out weekly as required .In respect to water temperatures these had not been checked regularly. Subject to requirements. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 24 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 2 3 3 X 2 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 X 3 X 3 LIFESTYLES Standard No Score 11 2 12 X 13 3 14 2 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 2 X X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holmbury Dene Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X X 2 DS0000025625.V269459.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4 Sched 1 Requirement The registered provider must ensure that the home’s statement of purpose is amended to include accurate details of the current registered manager The registered manager must ensure that all service users are issued with a contract outlining the terms and conditions of service users stay within the home and services and facilities to be provided. The registered manager must ensure that service users, their relatives and/or representative where appropriate are involved in the drawing up of care plans and support guidelines and these are signed to indicate their involvement. The registered manager must ensure that staff must be involved in the reviews of all service users who attend the home and a copy of the review is kept on service users files. The registered manager must ensure that the key worker system is fully implemented and DS0000025625.V269459.R01.S.doc Timescale for action 31/03/06 2. YA2 5 (1) (b), (c). 31/05/06 3. YA6 12 (2) & (3). 30/06/06 4. YA6 15 (2). 30/06/06 5. YA6 18 (1) (a) 30/06/06 Holmbury Dene Version 5.0 Page 26 6. YA8 16 (2) (n) & 24 (3) 7. YA9 13 (4) 8. YA11 12 (1) & (2) 9. YA23 13 (6) 10. YA32 18 (1) (c) 11. YA33 18 (1) (a) staff are fully aware of their responsibilities to undertake this role. (Previous timescale of 31/10/05 not met) The registered manager must ensure that work is done and evidence is provided that service users are offered opportunities to participate in the day-to-day running of the home. (Previous timescales of 31/03/05 and 31/10/05 partially met) The registered manager must ensure that comprehensive risk assessments are in place for all service users that these include control measures and an action plan to minimise the identified risk and these are regularly reviewed and updated. The registered manager must ensure that service users are provided with opportunities to learn and develop life skills and this is monitored and recorded within the service user plan. The registered manager must ensure that all staff are familiar with the home’s adult protection policy and procedures and that all staff receive adult protection training. The registered manager must ensure that 50 of support staff achieve the NVQ level 2 or 3 award. (Previous timescale of 31/12/05 not met) The registered manager must specifically define minimum staffing levels for the home to ensure that staff numbers and skill mix effectively meet service users needs. (Previous timescale of 30/09/05 not met) 30/06/06 30/06/06 30/06/06 30/06/06 30/06/06 30/06/06 Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 27 12. YA37 9 (2) (b) r The registered manager must (i) achieve the NVQ Level 4 in management and care. (Previous timescale of 28/02/06 not expired). CSA 28. The registered manager must ensure that all required licences and certificates are displayed within the home at all times. The registered manager must ensure that evidence is available that quality assurance tools in place are being implemented to allow the home to assess and improve its service and that this includes carrying out consultation with service user, relatives and other stakeholders involved in the service. (Previous timescale of 02/01/05 and 30/11/05 not met) The registered manager ensure that staff adhere to all health and safety procedures including fire safety and that a comprehensive environment /building and a fire safety risk assessment is completed. 30/09/06 13. YA37 28/02/06 14. YA39 24 (1) 30/07/06 15. YA42 13 (4) & 23 (4) 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered manager should consider introducing a format for service user plans that use a person centred approach to make information more easily understood by service users. The registered manager should consider cleaning the files and archiving any old and out of date information to make the information more easily accessible. DS0000025625.V269459.R01.S.doc Version 5.0 Page 28 2. YA6 Holmbury Dene 3. YA6 4. YA14 The registered manager should consider implementing the “End of Stay Reports” to help identify personal goals and changing needs and also to establish different periods service users are staying at the home. The registered manager should explore means of improving the system for planning weekly activities for service users on a group and individual basis and also to use the systems in place such as the “End of Stay Report” and the “Keeping Track Data “ form more effectively to monitor outcomes. Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Holmbury Dene DS0000025625.V269459.R01.S.doc Version 5.0 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!