Inspection on 06/12/05 for Scope - The Hollies

This inspection was carried out on 6th 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Scope - The Hollies 10/05/07

Scope - The Hollies 10/08/06

Scope - The Hollies 14/06/05

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 1 ,2 and 3 The Hollies Halton Brook Avenue Halton Brook Runcorn Cheshire WA7 2FU Lead Inspector Maureen Brown Unannounced Inspection 09:00 6 December 2005 th Scope DS0000005179.V262502.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 Scope DS0000005179.V262502.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. Scope DS0000005179.V262502.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Scope Address 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) 1 ,2 and 3 The Hollies Halton Brook Avenue Halton Brook Runcorn Cheshire WA7 2FU 01928 590168 SCOPE Martyn Swindell Care Home 9 Category(ies) of Physical disability (9) registration, with number of places Scope DS0000005179.V262502.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 9 service users in the category of PD (Physical disability) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 14th June 2005 Date of last inspection Brief Description of the Service: The premises of 1 - 3 The Hollies are owned by Liverpool Housing Trust, and are managed by Scope. The 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 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 DS0000005179.V262502.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out during the morning of 6th December 2005. The total time on site was five hours and forty minutes. The inspector spent half an hour planning the inspection by reviewing previous inspection reports and the service history. The inspection included a tour of all the bungalows, inspection of records and discussions with six service users, the registered manager and other staff on duty. Nineteen out of forty-three standards were assessed and some were met. Service Users, relatives and GP comment cards were distributed after this inspection. One GP comment card was received. Feedback from this inspection was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? The standard of décor and furnishings has improved in Bungalow Three with a new fridge, flooring in the lounge, corridors and two bedrooms have been deep cleaned and the corridor walls have been repainted. In Bungalow Two the lounge flooring has been replaced and the corridor walls repainted. Residents meetings have been restarted with records kept and made available to residents. A new vehicle has been purchased and made available for all residents to use. The cupboards storing hazardous materials now have locks fitted. Scope DS0000005179.V262502.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. Scope DS0000005179.V262502.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 Scope DS0000005179.V262502.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): 2 Full assessments of needs are carried out to ensure that the home can meet the residents’ needs. EVIDENCE: Care plans examined showed that assessments had been carried out with each person before moving into the home. However, the pre-assessment records are limited, as most of the residents have lived at The Hollies since the 1980’s. The information is basic and very little past history was recorded. The home now has a placement policy and procedure, which would be followed for a prospective resident. This includes introductory visits, funding, waiting list, admissions procedure, preparation, trial periods and reviews. A preassessment document is available, which covers all aspects of care and why the placement is required. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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, 9 & 10 The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. 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 and visiting professionals’ sheets. Risk assessments were not up to date. The resident or their family were not consulted with regard to the care plans and the resident or representative did not sign these. These were based on the assessed needs by the staff. This was a previous requirement and is reiterated. The care plans should be reviewed on a monthly basis, in conjunction with the residents. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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. However, some records had been completed in red and green ink. Black or blue ink is recommended for ease of reading and photocopying. Residents said that they had chosen the décor and furniture within their own bedrooms and staff stated that all residents had been involved in choosing the décor of the shared rooms. From the previous recommendation residents’ meetings had been restarted. These meetings, which are recorded, allow residents the opportunity to raise issues of concern or problems. The home’s policy on confidentiality includes details about the Data Protection Act 1998, keeping information confidential and the sharing information. Also included was information about record keeping detailing how long records must be kept. See requirement Nos. 1, 2 & 3 and recommendation Nos. 1 & 2. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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): 15, 16 & 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 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 one resident was going to the Trafford Centre to do Christmas shopping and another resident was going to the Blue Planet Aquarium. During the afternoon some residents were out at “lifestyles” sessions of cookery and gardening. Scope DS0000005179.V262502.R01.S.doc Version 5.0 Page 12 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. 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 has been replaced since the last inspection. The freezer was creating excessive amounts of ice within a short period of time and needed replacing. This requirement remains outstanding from the previous report and is reiterated. The three kitchens were maintained in a clean and tidy condition. Since the previous inspection the new fully adapted vehicle had been purchased and this has enabled residents’ to resume trips out. See requirement No. 4. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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): 19 Residents received support from the staff for personal care in accordance with their stated preference. 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. Visits to health professionals were recorded in the care plans, including visits to GP’s, opticians, chiropodists and dentists. These were up to date. The manager said a carer always attended appointments with residents. One GP commented that they were satisfied overall with the care provided to their patient. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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 the following standard(s): 23 Clear policies and procedure were in place to ensure that residents were protected from abuse, neglect and self-harm. EVIDENCE: The home’s Protection of Vulnerable Adults Policy was consistent with the “No Secrets” guidance from the Department of Health. A copy of Halton Social Services’ policy on Adult Protection was available within the home and was accessible to staff. Policies on whistle-blowing and challenging behaviour were also available. Discussions were held with the manager about Adult Protection procedures and he was able to demonstrate the procedure to be followed in this situation. He is also the Designated Adult Protection Advisor (DAPA). Seven of seventeen staff had undertaken training on Adult Protection Awareness. See requirement No. 5. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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 the following 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 freezer in bungalow three was in need of replacement. 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, which following a previous recommendation is now kept locked. Scope DS0000005179.V262502.R01.S.doc Version 5.0 Page 16 From a previous requirement regarding the flooring in bungalow Three in the lounge, two bedrooms and corridors had been deep cleaned and were improved. Also the walls of the corridor have been repainted. In bungalow Two the flooring in the lounge had been replaced following a previous requirement and the corridors had been repainted. All the bungalows had adequate heating, with low surface temperature radiators provided, and good levels of lighting. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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 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, 34, 35 & 36 The home manager provides clear leadership. Staff received support and training to enable them to meet residents’ needs. Recruitment policies have not been consistently followed resulting in residents receiving care from staff that have not been properly vetted. EVIDENCE: At the time of this inspection the agreed staffing levels were met. Three staff were on duty and the manager said that a member of staff sleeps-in on the premises each night. The manager, senior care staff and housekeeper support the care staff. Annual staff appraisals have not been undertaken and staff confirmed this. 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. Eight of seventeen staff had received formal supervision regularly. Five staff had not received formal supervision for eleven months. The staff said that formal supervision had been conducted in the past and records were kept. Supervision records were seen and covered areas such as training, aspects of care practice, key working with individual residents and Scope DS0000005179.V262502.R01.S.doc Version 5.0 Page 18 policies and procedures. The manager said that for supervision purposes the staff team was split between him and the two senior care assistants. Staff training records indicated that ten of seventeen staff had attended a moving and handling course; seven staff had attended adult protection awareness; nine staff had attended fire awareness and six staff had current first aid certificates. All staff must complete mandatory courses. 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. Since the last inspection some of the staffing issues have been resolved. This has enabled the senior care assistants to now be released to attend to the “managerial” part of their role. If the recruitment procedure had been followed this would have ensured that the staff were suitable to work with vulnerable people. Three staff files were examined and these showed that some pre-employment checks were carried out. However files indicated that application forms, references, proof of identity and health declarations had not been consistently sought. All staff had Criminal Record Bureau checks in place. See requirement Nos. 6, 7, 8 & 9. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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 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): 39, 40, 41 & 42 Residents’ records were kept safe and secure. Residents’ views had been used in the past for the planning for the home. Decisions are influenced by the information obtained from conversations with residents. Arrangements are in place to minimise the risk so that the safety and welfare of the residents is promoted. EVIDENCE: All policies and procedures seen were up to date and accurate. Records were not up to date, this included care plans, supervision and appraisals. Records were kept secure within the home. Residents confirmed that they had access to information kept about them. During discussions with the residents they 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”. Scope DS0000005179.V262502.R01.S.doc Version 5.0 Page 20 A satisfaction survey had been developed to obtain the views of residents’ and relatives. However, these had not been distributed. The last survey was completed in May 2004. This process should be restarted and the outcomes shared with residents’ and other interested parties. Safe working practices included visits from the fire safety officer and the environmental health officer, which had been completed satisfactorily. The gas safety, electrical safety and insurance certificates were in place and up to date. Fire alarm tests were being undertaken on a weekly basis and records kept. Emergency lighting tests were also being carried out on a monthly basis with records kept. Nine of seventeen staff had received fire awareness training. See requirement Nos. 10 & 11. Scope DS0000005179.V262502.R01.S.doc Version 5.0 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 X 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Scope Score X 3 X X Standard No 37 38 39 40 41 42 43 Score X X 2 3 2 3 X DS0000005179.V262502.R01.S.doc Version 5.0 Page 22 Yes 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 YA6 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 ensure that risk assessments are kept up to date. The registered person must replace the freezer in Bungalow Three. The registered person must ensure that all staff receives training in Adult protection from Abuse. The registered person must ensure that all pre-employment checks are completed for staff. The registered person must ensure that all staff members undertake mandatory training. The registered person must ensure that staff supervision is conducted at least six times a year. DS0000005179.V262502.R01.S.doc Timescale for action 31/01/06 2. YA6 15 31/01/06 3. 4. 5. YA9 YA17 YA23 15 23 13 31/01/06 31/03/06 31/03/06 6. 7. 8. YA34 YA35 YA36 19 18 18 31/01/06 31/03/06 31/03/06 Scope Version 5.0 Page 23 9. 10. YA36 YA39 18 24 11. YA41 17 The registered person must ensure that annual staff appraisals are undertaken. The registered person must ensure that the quality assurance process is completed on an annual basis. The registered person must ensure that all records are kept up to date. 31/03/06 31/03/06 31/03/06 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. 2. 3. Refer to Standard YA6 YA6 YA41 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 daily record sheets are completed in black or blue ink. The registered person should ensure that the financial procedures are reviewed. Scope DS0000005179.V262502.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Northwich Local Office 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 DS0000005179.V262502.R01.S.doc Version 5.0 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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