Inspection on 23/02/06 for The Hollies

This inspection was carried out on 23rd February 2006.

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

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

Other inspections for this house

The Hollies 08/07/08

The Hollies 28/11/06

The Hollies 21/12/05

The Hollies 17/02/05

The Hollies 14/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Hollies 81 High Street Yatton North Somerset BS49 4DW Lead Inspector Paul Grey Announced Inspection 23rd February 2006 09:30 The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 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 DS0000020231.V278104.R01.S.doc Version 5.1 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 DS0000020231.V278104.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Hollies Address 81 High Street Yatton North Somerset BS49 4DW 01934 876773 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) The Brandon Trust Ms Janet Wheeler Care Home 5 Category(ies) of Learning disability (5) registration, with number of places The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 5 Patients with Learning Difficulties excluding those detained under the Mental Health Act 1983 Staffing Notice dated 10/03/2000 applies Manager must be a RN on parts 5 or 14 of the NMC register Date of last inspection 29th November 2005 Brief Description of the Service: The Hollies is owned by the Brandon Trust and is registered to provide nursing care for up to five people with learning difficulties excluding those detained under the Mental Health Act. All residents have complex needs and exhibit challenging behaviour. The home is set in attractive gardens, close to shops and other local amenities. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection over a two-month period. As a consequence many of the standards inspected overlapped with the recent inspection. The Inspector conducted a tour of the premises, spoke with staff working at the home, spoke with service users and audited the homes documentation. The manager was present during the inspection and received feedback from the Inspector throughout the process. During inspection, the Inspector was struck by the limited communal space inside the building. Whilst the Inspector understands that the floor space meets national minimum standards, the Inspector observed that with 2 agitated service users the ground floor communal areas were at times quite claustrophobic. The Inspector noted a range of environmental issues that needed to be addressed. These generally focused around maintenance or damp within the building. The Inspector also noted some minor documentation issues, which need to be addressed by the manager. Documentation issues will be highlighted later in the report but generally speaking were not significant. Care within the home remains of a reasonable standard and the service users appeared well cared for and content. What the service does well: What has improved since the last inspection? The inspections were only 2 months apart, and no significant flaws were noted. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 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. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 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 The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 The Hollies has a statement of purpose, which can provide potential service users, or their representatives with sufficient information to make an informed choice about where to live. The staff team assess service users aspirations and needs. Potential service users know that the home will meet their needs and aspirations. The home is able to demonstrate its ability to meet the service users assessed needs. EVIDENCE: The statement of purpose continues to reflect the Philosophy of care and overall approach of the home. There has been no change service provision; the statement of purpose continues to meet national minimum standards. The home has not admitted a new service user for some time. The home currently has one bed available. The manager informed the inspector that a potential new service user would be invited to come for a meal and to meet the service user group. The home offers a probationary period for service users. This allows the home to ensure they can meet the service users needs and allows the service user an informed insight into life in the home. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 9 The inspector noted a range of in-depth assessments for two service user files sampled. Service user assessments were in the form of the Brandon trusts Person centred planning documents. The service users needs and preferences were reflected in the service users care plans. The inspector noted that these were written from the service users perspective and with positive regard to the service users needs and aspirations. This was good practice. The Inspector noted a number of inconsistencies with regards to reviewing care files. The Inspector discussed this with the manager who will address care plan reviews. Consequently there is no requirement. On auditing service user files, the Inspector noted that the home is able to demonstrate its ability to meet the needs of the service users admitted. The Inspector noted evidence of specialist support for service users, particularly from the community learning disabilities team. This was good practice. The Inspector noted evidence that staff have relevant skills and experience to meet the service users assessed needs. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 The home assesses service users changing needs. Staff at the home support service users in making decisions about their lives. Staff support service users to take risks as part all independent living. Service users know information about them is handled appropriately and confidences are kept. EVIDENCE: The inspector noted from the 3 care files sampled, evidence of regular assessment. The inspector noted documentary evidence from care files that service user assessments are used to generate appropriate care plans. The inspector noted the care plans also outlined any potential restrictions on service users choice. The inspector noted to occasions where the use of a quiet room was documented. This was to allow service users opportunity to take time out if distressed or angry. The inspector noted that service users all have the key worker. The inspector noted no unreasonable restrictions on service users freedoms or The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 11 human rights. The inspector noted that any potential restriction was care planned risk assessed and in the best interests of the service user. The inspector noted extensive and well-documented risk assessments. The inspector noted that the staff have attempted to identify both individual and immunity risk. The inspector noted documentary evidence to demonstrate that staff at the home had taken action to reduce all reasonable risks and had drawn up appropriate strategies to manage risk. The home stores service users files and records in a locked office. Files and records appeared accurate and the Inspector noted the home has policies on service user confidentiality. Training is also provided for staff, outlining professional ethics and the organisations expectations. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 15, 16 The home provides service users with opportunities for personal development. Service users are supported to take part in appropriate activities. Service users have appropriate relationships. Service users rights are respected. EVIDENCE: The Inspector spoke with staff, service users and audited care records. The Inspector noted evidence to indicate that the service supports service users to develop social, emotional and independent living skills via a range of external activities. The Inspector noted service users have access to an active day care program and is a range of activities with the staff. Should service users, which they can attend, church all appropriate religious ceremonies? The service users at the Hollies were involved in a range of the feeling activities outside of the home. These however did not include paid work. The manager informed the Inspector that if it was appropriate for the service user, staff would support them engaging in some kind of paid employment. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 13 Service users are supported to maintain links with their family, friends or associates outside of the home. The home also encourages visiting, (within reasonable social hours). Service users have the opportunity to make friends and would be supported to maintain intimate personal relationships should they choose. The Hollies, is run as informally as possible. House rules are kept to a minimum with the majority of household routines being designed to allow the service users to live together. Service users do perform chores around the household but these were not unduly onerous. During inspection the Inspector noted, staffing interacting well with service users and were not interacting exclusively with one another. The Inspector also noted the staff team dealt well with agitation and potential difficulties between 2 service users during the inspection process. The Inspector has previously commented on the difficulty of working with agitated service users in this environment. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users receive personal support in the way they prefer. Service users physical and emotional needs are met. Service users are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: The Inspector noted both documentary and staff statement evidence regarding the provision of personal support. The Inspector noted in the documentation that there was evidence that staff were aware of service users preferences regarding personal support that was given. Staff and service user statement indicated that the home has flexible times for service users going to bed, having baths and eating meals. These times are is flexible as is practical in dealing with a small community. The Inspector noted no undue restrictions on service users. The Inspector noted evidence of discrete prompting for personal hygiene in the service users notes. The Inspector noted evidence from both staff statement and documentation that service users health care needs were met. The Inspector could find evidence that the service users were registered with the GP and were given The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 15 appropriate access to National Health Service facilities were needed. The Inspector also noted evidence the service users health needs were monitored by the staff and appropriately documented. The Inspector noted evidence of thorough assessment of service user needs. The Inspector noted evidence that service users would not be able to safely administer their own medication. The Inspector noted evidence that an appropriate record was maintained of medication administered service users. The Inspector also noted evidence that medication in the home was handled in accordance to the medicines act 1968 and the guidelines from the Royal pharmaceutical Society. Administration of medication appeared safe and professional. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse and self harm. EVIDENCE: The Brandon trust provides regular staff training to identify and understand abuse. The trust, and the home have robust procedures for the reporting of abuse and its documentation. Staff spoken with were aware of what to do in the event of suspected abuse and which policies and procedures to follow. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 28, 30 Service users live in a homely and comfortable environment. Service users bedrooms suit their needs. Shared spaces complement and supplement service users own rooms. The premises were clean and hygienic. EVIDENCE: The premises on the whole were suitable for their stated purpose. The Inspector noted a variety of issues relating to the maintenance of the property. these have resulted in a number of requirements. The Inspector noted in particular that there was a considerable amount of damp in the dining room. The Inspector noted this to be evident on the external walls by the window and the door exiting the property. This is not acceptable and needs to be addressed by the trust. This is subject to requirement. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 18 The Inspector also noted the external electricity cupboard is un safe. The external doors need to be replaced, as they cannot be closed. The electricity meter and electrical connections into the house cannot be shut away and a partially exposed to the weather and inquisitive hands! This is subject to requirement. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, Service users benefit from clarity of staff were roles. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policies and procedures. EVIDENCE: Staff members at the home have Brandon trust is job descriptions. These are well detailed and comprehensive. Staff also go through an in-depth induction process allowing them to understand their role within the premises. The home has an effective staff team in sufficient numbers to meet the needs of service users on the premises. The Inspector also noted evidence of an appropriate staff skill mix on duty. The Inspector audited the homes off duty and noticed the home maintains reasonable rates of turnover and sick leave. The home operates Brandon trusts recruitment policies and procedures. The Inspector was unable to audit these as they are held sentry at the Brandon trust. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,40 Service users benefit from a well-run home. Service users benefit from the leadership style of the home. The homes policies and procedures safeguard service users best interests. EVIDENCE: The home benefits from the leadership of an experienced registered manager who is a level 1 nurse, has had in excess of 2 years management experience and has met the requirements of the national minimum standards. The Inspector noted from staff feedback and service users spoken with that those living and working at the home feel the manager is approachable, positive and inclusive of suggestions. The Inspector sampled 3 written policies and procedures at random. All were present. The Inspector noted staff at EEC access to the policies and procedures in accordance with national minimum standards. The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 2 27 x 28 3 29 x 30 2 STAFFING Standard No Score 31 3 32 x 33 3 34 3 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 x 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 x 3 x x x The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 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, Ca2 Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 24 Regulation 23 2 b Requirement The Inspector requires the external electricity cupboard be made good. The doors on the cupboard must be replaced with working lockable doors to prevent service users accessing the electricity conduit. The Inspector requires a radiator cover be installed in the mail service users room. The Inspector requires the mould and damp be addressed in the currently vacant room. The Inspector requires this is addressed prior to the room being used, or before the end of August, which ever comes first. The Inspector requires an appropriate container be used to store soiled hygienic pads. The practice of putting soiled pads in a yellow plastic bag on the floor must stop. This is unhygienic and bad practice. The Inspector requires the Brandon trust have a comprehensive professional assessment of damp on the premises. A copy of this report along with Brandon trusts plan DS0000020231.V278104.R01.S.doc Timescale for action 23/02/06 2 3 26 26 23 2 a 23 2 b 31/08/06 31/08/06 4 30 23 2 c 16 2 j 16 2 k 23/02/06 5 24 23 2 b 31/08/06 The Hollies Version 5.1 Page 23 of action must be forwarded to the commission by the date shown. The Inspector will schedule a focused inspection to look into this in September. 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 DS0000020231.V278104.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 The Hollies DS0000020231.V278104.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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