Inspection on 22/05/07 for The Hollies

This inspection was carried out on 22nd May 2007.

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

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

Other inspections for this house

The Hollies 26/02/07

The Hollies 17/10/05

The Hollies 27/06/05

The Hollies 17/12/04

The Hollies 01/05/04

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Thorndene

Insight - Eastchurch

Southfields

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Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 The Hollies 84 Barnham Road Barnham Chichester West Sussex PO22 0ES Lead Inspector Mr D Bannier Key Unannounced Inspection 22nd May 2007 09:45 The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 84 Barnham Road Barnham Chichester West Sussex PO22 0ES 01243 555230 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) www.unitedresponse.org.uk United Response Mr David Kim Oaten-Wareham Care Home 14 Category(ies) of Learning disability (14) registration, with number of places The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 14 male and/or female service users in the category of learning disability (LD) may be accommodated. Up to 8 service users may be accommodated in the main house Up to 6 service users may be accommodated in the bungalow. Only service users between the ages of 18 and 65 may be admitted Date of last inspection 26th February 2007 Brief Description of the Service: The Hollies is a care home registered to accommodate up to fourteen residents with a learning disability, aged 18 to 65. The Hollies is a detached property, with accommodation provided between the main house, consisting of eight bedrooms across two floors and an attached bungalow that accommodates six Service Users. All areas are accessible to service users via a passenger lift if necessary. Some of the bathrooms are specially adapted for people with a disability and everyone has their own room. In addition there are extensive grounds that can be easily accessed by the residents. The home is located in a residential area of Barnham, with easy access to nearby bus and train services. The current scale of weekly charge is £704 to £720 per week. Additional charges are made for personal items. The registered provider is United Response, for whom the Responsible Individual is Mr T Jones. The registered manager is Mr D Oaten-Wareham. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been written using methodologies introduced on 1st April 2006. Some evidence used to assess standards has been gathered before this visit took place. For example, information has been used from information supplied by the provider in an Annual Quality Assurance Assessment (AQAA), which is the provider’s own assessment about how this service is being conducted; information has also been used from written reports of visits to the care home made by representatives of the registered provider. This visit was unannounced and started at 9.45am. It took place over six hours. The inspector spoke to three of the fourteen residents who are currently living at The Hollies. This gave the inspector a picture of how it is to live at this care home. The inspector also considered information provided by three residents and one relative in questionnaires issued by the Commission entitled “Have Your Say.” The inspector also spoke to two staff who were on duty. This helped the inspector to gain a sense of the work staff are expected to do. The inspector saw the communal areas and some of the private accommodation, with the permission of the residents living there. Some records were also examined. The inspector looked at those standards that are about how new residents are admitted to the care home; how residents are cared for; the daily life and social activities provided for residents; how the care home deals with complaints and how they protect residents from abuse; the environment in which residents live; how staff are recruited and trained; and how the care home is managed. David Oaten- Wareham, the registered manager, was present for part of the inspection. Other members of staff on duty also present during the inspection. The manager and his staff kindly assisted the inspector with his enquiries. What the service does well: The care home continues to provide good quality care to residents with learning disabilities. Residents are provided with opportunities to exercise choices on a daily basis about the lifestyle they wish to pursue and decisions affecting their wellbeing. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 6 The staff team is provided with a wide range of training to ensure they have the necessary knowledge and skills to work effectively with the residents accommodated. Staffing levels provided are sufficient to meet the varied needs of residents accommodated. A quality assurance system is in place, which ensures the views and opinions of residents and their families are taken into account. This ensures the care home is being run in the best interests or the residents. What has improved since the last inspection? The manager has ensured there is an appropriate means of assessing the needs of potential residents before they are admitted. This will mean that the manager and his staff will know they can meet the needs of new residents before they are admitted. The manager is in the process of reviewing care plans to ensure they contain up to date information about the current care needs of residents. This will mean all staff will have the necessary information about residents’ care needs so they know what they should do to meet them. All residents have been issued with an up to date contract. This will mean residents and their families will know the level of care and services the Hollies can provide. The registered manager has organised the staff team in undertaking to clean the premises in order to improve the standards of hygiene throughout the home. The registered manager has also been preparing a maintenance programme to ensure necessary improvements are made to the general upkeep of the premises. This will include a programme of redecorating some areas and replacing some carpets. The registered manager has reviewed and, where necessary, made improvements to practices of monitoring and dealing with issues related to Health and Safety. This will mean that the safety and wellbeing of residents and staff is being protected. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system is in place to ensure all new residents needs have been assessed prior to admission. The registered manager has ensured all residents have been issued with a standard form of contract. EVIDENCE: During the last inspection there was no evidence to confirm residents needs had been assessed prior to admission. There have been no new residents admitted since the last inspection. However, the manager informed the inspector at this inspection that the current practice is to use an assessment form, which is included in the provider’s quality assurance manual known as “Getting It Right.” During the last inspection the inspector looked at one contract and found it to be out of date and not signed by either the resident, a representative or the registered manager. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 10 Records seen at this inspection confirmed that all residents have been issued with the provider’s standard form of contract. The manager and the individual resident concerned have signed and dated this document to confirm they have been issued since the last inspection. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has started the process of ensuring all residents care plans and care records are reviewed regularly to ensure they reflect the changing needs of residents. The registered manager has ensured residents can make decisions about their lives with assistance as needed. Staff are expected to support residents in taking risks as part of an independent lifestyle. EVIDENCE: During the last inspection there was no evidence of residents’ involvement in drawing up their own care plans and care plans were not reviewed on a regular basis. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 12 Records seen on this occasion indicated that care plans are in the process of being reviewed. This process includes discussions and consultation with each resident. Minutes of staff meetings indicate that the manager has discussed this matter with staff and is monitoring progress. A report of a visit made by a representative of the provider to the care home indicated that the provider has been made aware that a number of actions have been identified by the Area Manager and by CSCI which need attention. This report noted that the service has worked hard to rectify these but some further work is still to be completed on record keeping, care plans and risk assessments. In summary the report concluded that, “All service users now have an up dated assessment of need…” During the last inspection there was evidence to confirm that residents attend regular resident meetings. At these meetings menus for the forthcoming week are discussed, with each resident putting forward a meal suggestion. Some residents returned satisfaction surveys to the inspector prior to this inspection. One resident commented, “I choose how to spend my day, who I spend my time with, what I eat and when, what time I get up and go to bed.” Another resident said, “I have choices about when I get up and go to bed.” The relative of a resident returned a survey and confirmed that this care service always supports people to live the life they choose. From direct observations and discussions with residents the inspector concluded that staff actively support residents in making decisions about daily activities. The inspector observed one resident was taking part in staff interviews on the day of this inspection. The resident was responsible for showing each candidate around and providing them with information about the Hollies. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to take part in a range of activities, including leisure activities, appropriate to their needs. Residents are part of the local community. Residents are supported in having appropriate relationships with friends and family. The registered manager has ensured residents have offered a healthy diet. Meals and mealtimes have been provided in a manner which meets the needs of individual residents. EVIDENCE: The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 14 During the last inspection there was evidence to confirm that residents take part in a range of activities including college placements and voluntary work placements. Visual presence within the community is high; residents travel independently around the local area to shops and to leisure services and facilities. Surveys returned by residents prior to this inspection included comments such as, “I go to banks/shops when I want to,” and “I have freedom to choose what activities I do and when I do them.” Another resident commented, “I make decisions about what college I go to and what course I do.” Information returned by the registered provider prior to this inspection confirmed that residents have access to local amenities; several have paid jobs whilst others go to a local day centre. From evidence gathered during this inspection the inspector concluded that residents are encouraged to maintain contact with families and friends if they wish to do so. One resident stated in a survey that, “ I stay at my mum’s once every second week.” The registered provider has also confirmed that residents are supported to maintain links with family and are supported individually to maintain and build other friendships and relationships. The registered provider has also confirmed that they have enlisted the support of the Community Team for People with Learning Disabilities (CTPLD) when residents have needed help with forming sexual relationships. During the last inspection there was evidence to confirm that menus have been written up weekly, incorporating individual choice. Residents cook meals with support from staff. One resident confirmed that meals are okay “most of the time.” At this inspection residents stated in surveys that, “I do my jobs and housework at a time that is convenient to me and cook when I want to. I choose to eat in my own room, I don’t have to spend time with other service users if I don’t want to.” Comments made by the registered provider in information returned before this inspection confirmed that all residents have been supported in drawing up their own menu each week. Some residents have their own menus and have been supported to do their own shopping, budgeting and cooking. The registered provider has also identified that an improvement made during the past 12 months has been that they have worked with people in developing more individual and flexible cooking times. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have received personal care and support in a way that suits their individual needs and preferences. Residents’ physical and emotional health care needs have been met. The registered manager has ensured residents are protected by the manner in which the care home deals with medication. Where appropriate residents manage their own medication. EVIDENCE: During this inspection there was evidence in care records that confirmed that residents have been consulted with regard to how they wish to be cared for. Following review meetings with residents, care plans are amended where necessary to include the personal preferences of the resident. This will mean staff will have clear instructions with regard to how care should be provided. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 16 One resident confirmed that staff always listen and act on what they say. Comments received in a survey stated that, “Staff will make time to listen to me and help me if I have problems. They speak to me in private, which I like.” Another resident confirmed that staff sometimes listen and act on what they say, commenting, “ When staff have time they listen and try to support me, but sometimes they are with other residents, so don’t have time to listen. I have weekly house meetings with other residents and a monthly one to one meeting with my key worker to discuss what I want and need.” Information supplied by the registered provider prior to this inspection confirmed that all residents’ preferences about how they want to be supported in personal care has been included in their care plan. Evidence gathered during the previous inspection confirmed that medical appointments have been and residents have been supported in attending them. However, concern was expressed regarding the poor documentation of such appointments and their outcome. Records seen during this inspection indicated that care plans and care records are in the process of being reviewed to ensure they include all necessary information about the physical and health care needs of residents. This process has included discussions and consultation with each resident. Minutes of staff meetings indicate that the manager has discussed this matter with staff and is monitoring progress made towards making required improvements. Information supplied by the registered provider confirmed that individuals are supported with all appointments and visits to practitioners. A satisfaction survey completed by a relative confirmed that the care home always meets the needs of their relative. Evidence gathered during the previous inspection indicated that medication has been retained in individual residents’ rooms. These had been appropriately stored and records of such medication were accurate and up to date. Risk assessments have been carried out on those residents wishing to manage their own medication to confirm they are capable of doing so. Information supplied by the registered provider prior to this inspection confirmed that medication systems have been developed which meets the needs of residents and ensures their safety. Plans for improvement in the next 12 months include simplifying systems to ensure they are easily understood, yet ensuring the means of monitoring them are robust. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has ensured residents feel their views are listened to and acted on. The registered provider has ensured residents are protected from abuse, neglect and self harm. EVIDENCE: The last inspection report confirmed that comprehensive policies are in place using a step-by-step approach to dealing with comments, concerns and complaints. The complaints procedure has been produced in Picture Book format ensuring all residents understand how they should make a complaint. Surveys returned by residents, prior to this inspection confirmed that one resident always knows how to make a complaint. This resident commented, “If I am unhappy I always tell the staff and I am aware of the complaint procedure. I sit down with staff who help me to fill in the form and a manager will investigate. If I am still not happy I know I can complain higher up to the area manager.” Two residents confirmed they sometimes know how to make a complaint. Comments made included, “I know about the complaints procedure. I know the staff will fill a complaints form for with me,” and “I use the The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 18 complaints form procedure and I also tell the staff if I am not happy about anything.” Information returned by the registered provider prior to this inspection confirmed that there is a good complaint system in place that is designed around the residents. Residents are also regularly encouraged to express their views in house meetings and key worker meetings. The registered provider has also identified complaints training for staff as an area for improvement over the next 12 months. Evidence gathered during the last inspection confirmed that the home’s policies and procedures regarding adult abuse are comprehensive. The majority of staff had attended training in this area and were able to demonstrate their awareness of their responsibilities. Information supplied by the registered provider, prior to this inspection confirmed that staff have been trained in the Adult Protection procedures. Newly recruited staff have also been thoroughly vetted before starting work at this service, including enhanced criminal record checks. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has started the process of regularly cleaning the premises and carrying out necessary maintenance work to ensure all residents live in a homely, comfortable and safe environment. The home is clean and hygienic. EVIDENCE: The inspector toured premises with a member of staff. The manager joined us briefly. He was involved in interviews all day, but was able to join us when he could. During the last inspection it was found that the hallway carpet in Hollies was very badly stained generally, but especially around the kitchen and toilet area. There was clear evidence at this inspection that attempts had been made to clean the carpet. The manager advised that this had been done with sugar The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 20 soap as some residents could not tolerate the carpet being cleaned with chemicals. Some residents like to walk around with bare feet and had experienced an allergic reaction. The manager confirmed that he has secured funding to replace the carpet. However, he is currently researching what would be the most suitable replacement given the current needs of residents. He advised the inspector that the carpet would be replaced within the next 6 months. During the last inspection the kitchen/diner, although improvement work had been carried out, was still shabby and dirty in many areas, including several cobwebs with spiders and dead insects in them. It was clear from direct observation that this area had been thoroughly cleaned. The manager advised the inspector that the area had also been redecorated. When asked how he would ensure a good standard of cleanliness would be maintained in this area the manager produced a cleaning matrix. Staff are expected to clean allocated areas throughout the premises every day and to sign when this has been done. Minutes of staff meetings indicated that the manager has discussed this matter with staff and is monitoring progress. Residents were asked in a satisfaction questionnaire to comment on whether the care home is fresh and clean. One resident commented, “The house is cleaned daily by staff and service users. Some people are messy and don’t clean up after them which can be annoying but usually the house is clean.” Another resident stated, “ I think the house is always dirty. The floors are dirty and the bathrooms. Sometimes people spill drinks and don’t clean up afterwards.” During the last inspection the inspector noted that in the toilet/shower room next to the kitchen there was a very strong, foul smell, The Registered Manager said they were currently investigating this, but as yet, without success. The inspector was advised at this inspection that there was no change, the plumber was still carrying out investigations. The inspector looked into the toilet and noted the foul smell was still present. The inspector also noted that, despite this, residents were still using the toilet. The inspector asked the manager if he had thought it might be good idea to make the facility unavailable to residents until the problem had been dealt with. It did not appear as if this course of action had been considered. A report of a visit made by a representative of the provider to the care home indicated that the provider was aware of the problem and was having it investigated. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 21 During the last inspection the Inspector looked at four bedrooms further down the hallway. Whilst individual in layout, they also looked tired and worn. Outside one of the bedrooms there was a patch of repair work that had not been repainted. The manager confirmed that these areas had yet to be repainted. The manager also confirmed that no further action had taken place regarding redecoration, but also advised the inspector that he was confident he was on target in terms of completing outstanding requirements within agreed timescales. The timescale set at the last inspection for this work to be completed was 30/06/07. As the work identified has not yet been completed the requirement has been restated in the appropriate section of this report. Information supplied by the registered provider prior to this inspection indicated that a maintenance programme would be developed over the next 12 months. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered provider has ensured residents have been supported by competent and qualified staff. The registered provider has ensured residents have been protected by the home’s recruitment policy and practices. The registered provider has ensured residents’ needs have been met by appropriately trained staff. EVIDENCE: At the last inspection the registered manager informed the inspector that it is the intention of the registered provider for the twelve permanent staff employed at the care home to have the National Vocational Qualification in care at Level 3. However, at the time, only two of the team had completed the training whilst six were in the process of completing it. Information supplied by the registered provider prior to this inspection confirmed that now three staff have completed this qualification and there are four who are in the The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 23 process of completing it. In addition, all staff have been provided with induction training and a staff development programme that meets the appropriate standards for this service. Two residents completing surveys confirmed that staff always treat them well. They commented, “Staff are friendly. They knock on the door before they come into my room,” and “If I am upset they help me calm down. They are nice and polite. They knock on my door before they come into my room.” One resident confirmed staff sometimes teat them well and commented, “Sometimes staff are busy and I have to wait before I speak to them, which is annoying. Living in residential care means staff time is divided between service users and I don’t have access to staff when I need them. Staff are polite and don’t tell me what to do.” During the last inspection the inspector examined recruitment records and found they contained the relevant information required to ensure the protection of service users. Information supplied by the registered provider prior to this inspection confirmed that staff have had all relevant checks carried out on them before starting at this care home. All staff go through induction training in their first three months of employment. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered provider has ensured the Hollies is being well run. The registered provider has ensured residents’ views are taken into account during the process of self-monitoring, review and development of the service. The registered manager has made the necessary arrangements to ensure the safety of residents and staff have been promoted and protected. EVIDENCE: The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 25 During the last inspection, evidence gathered confirmed that Mr David Oaten – Wareham, the registered manager, has the necessary skills, knowledge and experience to manage this service. Mr Oaten-Wareham has continued to develop his knowledge and understanding of management issues by attending appropriate training events. The most recent of which have included understanding and implementing staff disciplinary procedures and effective management of staff sickness. There was also evidence at the last inspection to confirm that quality assurance questionnaires are sent out annually to all residents. Visits are made to the Hollies on an unannounced basis by a representative of the registered provider to monitor the care and services provided. The inspector saw the most recent report of such visits and concluded that this person spends time speaking to residents in order to here their views about the service provided. The registered provider has also organised a “Parents Forum” to discuss future plans for the service. This meets every four months and relatives are encouraged to attend to learn about and discuss the plans to prepare residents who are able for supportive living. Information provided by the registered provider, prior to this inspection confirmed that residents are encouraged to become involved in the day to day running of the care home. Residents, their families and staff who work in the Hollies are encouraged to question the management of the care home. Quality assurance questionnaires are sent to residents to find out their views about the service. Visits by representatives of the registered provider are carried out monthly, and a senior member of staff carries out organisational audits regularly. During the last inspection it was discovered that products considered harmful under Care of Substances Hazardous to Health (COSHH) regulations were found in a cupboard, and despite having a lock on the door, it had been left open. Such items must be kept locked away when not in use. The manager advised the inspector that the cupboard in question was located in the toilet with the foul smell, the inspector noted that this cupboard was locked. The inspector also noted that this was an item for discussion at all staff meetings. Staff have been advised to be vigilant regarding health and safety issues. The manager has devised a matrix which all staff are expected to complete when necessary checks have been carried out. During the last inspection it was noted that due to the nature of the service, there are a significantly high number of incidents and accidents recorded, including medication errors. The inspector noted that there is no system in place for following up or reviewing how and why these incidents happen, and therefore how to reduce them, despite clear guidelines to do so. The inspector also noted that the Commission had not been notified of many of the incidents. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 26 The manager informed the inspector of an incident which had recently occurred. He also advised the inspector that he would be informing the Commission of this in writing as required. The inspector can confirm that the Commission has now received notification of this incident. Information supplied by the registered provider prior to this inspection indicated that the premises and equipment are serviced and regularly maintained. This includes gas and electrical installations, fire detection and fire prevention equipment. Information supplied also confirmed that it the provider’s intention to make the following improvements over the next 12 months: to ensure all Health and Safety issues are monitored; to ensure the Commission is notified of all events affecting the wellbeing of residents; to monitor all accidents and incidents affecting residents. The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 28 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 YA24 Regulation 23 Requirement All parts of the care home are to be kept clean and reasonably decorated. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Hollies DS0000014779.V336234.R01.S.doc Version 5.2 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. 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