Inspection on 14/06/05 for Scope - The Hollies

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Scope - The Hollies 10/05/07

Scope - The Hollies 10/08/06

Scope - The Hollies 06/12/05

Scope - The Hollies 21/02/05

Scope - The Hollies 18/08/04

Scope - The Hollies 22/02/04

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

CARE HOME ADULTS 18-65 SCOPE The Hollies 1, 2 and 3 The Hollies Halton Brook Avenue Halton Brook WA7 2FU Lead Inspector Maureen Brown Unannounced 14 June 2005 9:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Scope 1-3 The Hollies Address 1-3 The Hollies Halton Brook Avenue Halton Brook Runcorn WA7 2FU 01928 590168 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) SCOPE Martyn Swindell Care Home 9 Category(ies) of Physical disability (9) registration, with number of places SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for a maximum of 9 service users in the category of PD (Physical disability) 2 The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Date of last inspection 22/02/05 Brief Description of the Service: The premises of 1 - 3 The Hollies are owned by Liverpool Housing Trust, and are managed by Scope. The care home is located in the Halton Brook area of Runcorn with easy access to local amenities and facilities. The Home is comprised of three bungalows accommodating nine service users in total who are physically disabled. Each bungalow provides three bedrooms and a shared kitchen/dining area, lounge, bathroom, separate shower room, a utility room and brick built outdoor shed. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out during the morning of 14th June. The total time on site was five hours. The inspector spent an hour and a half planning the inspection by reviewing previous inspection reports and the service history. The inspection included a full tour of the home, inspection of records and discussions with eight service users, the registered manager, two senior care assistants and a care assistant. Twenty out of forty-three standards were assessed and most were met. Feedback from this inspection was given to the two senior care assistants at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Completion of care plans needs to be improved. The resident and their carer must be consulted regarding the service user care plan and the resident or carer must sign it. The service user care plan should be reviewed on a monthly basis. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 6 The standard of décor and furnishings needs to be addressed. The fridge and freezer in Bungalow Three must be replaced. Flooring in Bungalow Three in the lounge, corridors and two bedrooms must be replaced and the corridor walls are in need of redecoration. Flooring in the lounge in Bungalow two must be replaced and the corridor walls must be redecorated. Residents meetings should be held on a regular basis with records kept and made available to residents. Appropriate transport needs to be made available for all residents to use. For reasons of safety the cupboards storing hazardous materials should have locks fitted. Following a recent theft in the home financial procedures should be reviewed. Requirements and recommendations have been made regarding each of the above points. For details please see pages 22 and 23. 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. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3 Sufficient information is provided for residents to make a decision about moving into the home. Full assessments of needs are carried out to ensure that the home can meet the residents’ needs. EVIDENCE: Each resident had a copy of the home’s statement of purpose and function and the service users guide. This was kept in the resident’s bedroom. A copy of the most recent inspection report was available in the office and staff were aware of this. Care plans examined showed that assessments had been carried out with each person before moving into the home. Residents confirmed they were not directly involved in the care plan process. Care plans were based on the perceived assessed needs of the resident. Residents had visited the home prior to admission and trial overnight visits were encouraged. Admissions were planned and ranged from a short visit to overnight stays, dependent on the needs and wishes of the person. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. Residents’ make decisions about their preferences with support from staff as needed. EVIDENCE: A sample of three residents’ care records was seen during this inspection. These were comprehensive and well presented in individual folders. Each contained care plan monitoring sheets, personal information, 24-hour summary sheets, visiting professionals’ sheet and risk assessments. The resident or their family were not consulted with regard to the care plans but these were based on the assessed needs by the staff. Residents or families must be involved in the care plan process and must sign the care plans. (See requirements No 1 & 2). The care plans should be reviewed on a monthly basis, in conjunction with the residents. (See recommendation No 1). SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 10 Daily record sheets seen showed that day-to-day activities were recorded. This enabled staff and family members to see what a particular resident was undertaking during the day. They were written clearly, easy to follow and were signed by carers. Residents said that they had chosen the décor and furniture within their own bedrooms and staff stated that all service users had been involved in choosing the décor of the shared rooms. Each of the three bungalows held residents’ meetings with staff, however, these had not been conducted for some time. The senior care assistants said that this was due to staffing shortages. Residents’ meetings, which are recorded, allow residents the opportunity to raise issues of concern or problems. Resident meetings should be held on a regular basis and records kept. (See recommendation No 2). During this inspection residents were heard to be choosing their own clothing, prior to going out for the afternoon. Also staff checked with service users about where they wanted to be within the home. One resident indicated that they would like to go to their own bedroom. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13 &17 Residents’ were able to take part in a range of activities of their choosing. Personal and family relationships were encouraged by the home and the staff team supported people with this. Residents’ dietary needs were well catered for with a balanced and varied selection of food that met peoples’ tastes and choices. EVIDENCE: The residents’ plans reflect the range of activities undertaken which included a lifestyle programme of crafts, music, information technology, working on an allotment and going out and about in the community. During this inspection it was observed that some residents were out at crafts and cookery and gardening sessions. Visits from family and friends were recorded in the care plans and case notes. Residents shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the shared lounge/dining area. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 12 Residents liked to visit friends in the other parts of the home and said staff helped them with access if necessary. The menus for the three bungalows were seen and these reflected peoples’ personal choices. Special diets were catered for such as soft diets. A meal was seen being served in one of the bungalows and it reflected the individual choices of the three residents’ as three different meals were prepared. After the meal residents said that they had enjoyed it. Fridge, freezer and hot food temperatures were recorded and seen by the inspector. The fridge in bungalow 3 was recorded as having a consistently high temperature and the freezer was creating excessive amounts of ice within a short period of time. Staff said that it had been defrosted during the previous week. At the time of this inspection ice was several inches deep. Both the fridge and freezer should be replaced to ensure that foods are stored at the correct temperature. (See requirement No 3). The three kitchens were maintained in a clean and tidy condition. The staff said that the home did not have a van available at the moment to take residents out into the community. A new one had been ordered and they had access to a car, but not all the residents could use a car. The lack of appropriate transport and staffing issues meant that residents’ trips out were limited. (See recommendation No 3). SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 &20 Residents received support from the staff for personal care in accordance with their stated preference. Administration and control of medications were appropriate for the needs of the service users. EVIDENCE: The sample 24-hour summary records seen described how the residents preferred to be supported in their daily routines. Times for rising and resting preferred moving and handling techniques and personal care preferences were recorded, as was choice of clothing, hairstyle and makeup. All residents were dressed differently according to their own choice. At lunchtime choice of clothing was observed being offered to a resident by one of the care assistants on duty. In each bungalow a locked steel cupboard was available for storage of medication. This was located within the bathroom. A monitored dosage system was used and all medication was stored appropriately. The medication administration sheets seen were signed and up to date. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Residents were satisfied with the support they received from the manager and staff. EVIDENCE: The home’s policy on complaints was seen and residents said that they would speak to the staff if they had a complaint. Staff confirmed that they were aware of the procedure and would pass concerns onto the manager. A blank complaint form was seen in each resident’s file for their use. No complaints had been received since the previous inspection and all relevant paperwork was available in the event of a complaint being received. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The home provided a clean environment for the people to live in. EVIDENCE: All three bungalows were visited during this inspection. Each was furnished in a domestic style with additional equipment such as hoists and tracking provided as necessary to meet the residents’ needs. Residents said that bedrooms were decorated to their preferred style and staff said that shared lounge and dining areas were decorated with residents’ involvement in the colour scheme chosen. Each bungalow was clean, tidy and free from unpleasant smells. Records of menus and daily checks on fridge, freezer and hot food temperatures were kept. The fridge and freezer in bungalow three was in need of replacement (see requirement No 3). The tumble driers were located in the kitchens to allow for external ventilation. Each bungalow has a separate laundry room, which had domestic style washing machines. Cleaning materials were kept in a high level cupboard. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 16 Although residents’ would not be able to get to this cupboard, it was recommended that locks be fitted to them, as a health and safety precaution. (See recommendation No 4). A full set of hazardous substance data sheets were available and staff said they were aware of this file and that chemicals must not be mixed with other chemicals. A random sample of hot water temperatures were taken throughout the three bungalows and these were recorded at between 40 – 43 degrees centigrade. Within the recommended guidance of 43 degrees centigrade. Within bungalow Three the flooring in the lounge, two bedrooms and corridors were badly stained and need replacing. (See requirement No 4). Plaster along the walls of the corridor was damaged and generally the walls needed repainting. (See requirement No 5). Within bungalow Two the flooring in the lounge is badly stained and needs replacing. (See requirement No 6). Also, the corridors need repainting. (See requirement No 7). All the bungalows had adequate heating, with low surface temperature radiators provided, and good levels of lighting. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 36 The home manager provides clear leadership. Staff received support and training to enable them to meet residents’ needs. EVIDENCE: At the time of this inspection the agreed staffing levels were met. The manager said that annual staff appraisals were due to be undertaken over the next three months. Staff said that they had not yet had an appraisal. Observed day-to-day supervision of staff was good and the staff team confirmed that they were supported by the manager and two senior staff in their delivery of care to residents. The staff said that formal supervision had been conducted on a regular basis and records were kept, however, recently this had not taken place due to staffing problems. Supervision records were seen and covered areas such as training, aspects of care practice, key working with individual residents and policies and procedures. The manager said that for supervision purposes the staff team was split between him and the two senior care assistants. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 18 Staff training records indicated that most staff had attended moving and handling, adult protection from abuse, fire awareness and first aid courses. Other courses also undertaken included food hygiene, medication and NVQ training in Care. The manager said that ten out of seventeen staff had completed NVQ level II in Care. Staff said they were encouraged to attend training sessions. It was seen that the senior care assistants were regularly used to cover duty shifts in the bungalows. This was because four staff members were on long term sick, one on maternity leave and holiday cover. Although staff had covered the majority of these shifts it has meant that the senior care assistants had not been able to attend to the “managerial” part of their role. It is recommended that this be reviewed. (See recommendation No 6). SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 41 Residents’ records were kept safe and secure. The manager is competent, experienced and able to meet the homes stated purpose aims and objectives. EVIDENCE: The manager is continuing with the NVQ level IV Registered Managers Award and said that he had three units to complete. He was working towards completing this award in the next three months. From discussions with the manager it was evident that he was aware of Scopes’ written aims and objectives and the policies and procedures. Staff said the manager supported them in their role. All records, policies and procedures seen were up to date and accurate. These were kept secure within the home. Residents confirmed that they had access to information kept about them. During discussions with the residents they SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 20 said that the manager was easy to approach and that he visited each bungalow regularly. Residents said that they “liked living in the home” and “that the home was run well”. Following a recent theft within the home it is recommended that the financial procedures be reviewed. (See recommendation No 5). SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x 2 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 SCOPE The Hollies Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 3 x x F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15 Requirement The registered person must ensure that the resident and their carer are consulted regarding the service user care plan. The registered person must ensure that the resident or carer must sign the service user care plan. The registered person must replace the fridge and freezer in Bungalow Three. The registered person must ensure that the flooring in Bungalow Three in the lounge, corridors and two bedrooms are replaced. The registered person must ensure that the corridor walls in Bungalow Three are redecorated. The registered person must ensure that the flooring in the lounge in Bungalow Two is replaced. The registered person must ensure that the corridor walls are redecorated. Timescale for action 30.9.05 2. 6 15 30.9.05 3. 4. 17 24 23 23 30.9.05 30.9.05 5. 6. 24 24 23 23 30.9.05 30.9.05 7. 8. 24 23 30.9.05 SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 23 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. 4. 5. 6. Refer to Standard 6 6 17 30 41 36 Good Practice Recommendations The registered person should ensure that the service user care plan is reviewed on a monthly basis. The registered person should ensure that residents meetings are held on a regular basis and records kept. The registered person should ensure that transport is available for all residents to use. The registered person should ensure that cleaning materials are stored in a locked cupboard. The registered person should ensure that the financial procedures are reviewed. The registered person should ensure that the senior care assistants have time to attend to the “managerial” part of their role within the working week. SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 SCOPE The Hollies F51 F01 S5179 The Hollies V232611 140605 Stage 4.doc Version 1.30 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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