Inspection on 24/05/05 for The Hollies

This inspection was carried out on 24th May 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 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 10/07/06

The Hollies 09/11/05

The Hollies 05/01/05

The Hollies 20/10/04

The Hollies 20/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Hollies Church Road Shustoke Coleshill Birmingham, B46 2JX Lead Inspector Sheila Briddick Unannounced 24 May 2005 09:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Hollies Address Church Road Shustoke Coleshill Birmingham B46 2JX 01675 481139 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Alison Thorneywork & Mr Anthony P Shepherd Mrs Alison Thorneywork PC 3 Category(ies) of LD 3 registration, with number of places The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No new admissions are to be made to the home until the registered Manager has successfully completed the following training and provided documentary evidence to the Commission for Social Care Inspection: a) b) The Learning Disability Award Framework Induction and Foundation Modules. A Dementia Awareness course, approved in writing prior to enrolment by the Commission for Social Care Inspection. Date of last inspection 5 January 2005 Brief Description of the Service: The Hollies is a detached house located in the small village of Shustoke, which is an about 1 ½ miles out of Coleshill. The home is currently registered for 3 people with Learning disability, men or women. However the Commission for Social Care Inspection has imposed a Condition on the registration of the home that no new admissions are made until the registered person has successfully completed an agreed programme of professional training. The property is set in about 3 acres of land and is also home to a number of animals and house pets. The ground floor consists of two lounges, a toilet, kitchen/dining area and a utility room. Upstairs are five bedrooms, two bathrooms and a toilet. The registered provider manages the home and also lives there. The home has limited off the road parking in front of the main gate. A large amount of parking space is available if needed beyond the gate. A bus service goes through the village hourly. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the day over a four-hour period. Service users were met during the inspection and care plan records and staff training records were examined. A tour of the building and grounds was undertaken. Following the last inspection visit a Condition was imposed on the homes registration under Section 17 (4) of the Care Standards Act 2000. The Condition stated that no new admissions of the made to the home until the registered provider successfully completed training in the Learning Disability Award Framework Induction and Foundation Modules and Dementia Awareness. The registered provider was requested to attend a meeting with the Commission for Social Care Inspection February 2005 to discuss the future of the service. Solihull Social Services Department were represented at this meeting. The registered provider is now able to provide documentary evidence that the necessary training imposed by the condition has been accessed by the registered provider and carer. The registered provider however has only partially completed the Dementia Care Awareness training programme. This requires completing. What the service does well: The people living in this home have good relationships with the people who care for them. The environment is warm and welcoming and the people living in the home are involved in the daily living activities as part of the lifestyle of living on a smallholding. Service users are encouraged and supported to continue their own hobbies and interests, which includes music, singing and holidays that service users wish to take. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5 Information about the services and facilities in this home are available for prospective users when making a decision about whether the service will be able to meet their needs. This does not include information about disability access on the ground floor. Terms and conditions of residency are agreed with service users and a written contract is made. EVIDENCE: The Statement of Purpose is clear about the services and facilities available at this home and includes descriptions of the lifestyle involved where pets and animals are kept. Information necessary for people with a physical disability about ground floor facilities not being available however has not been included. The Statement of Purpose is clear that care management assessments are necessary as part of the admissions process to identify whether this service can meet the needs of the prospective user. Each service user has a written contract of terms and conditions and has signed the contract when able. Family or friend support for service users when agreeing contracts has not been considered. This support is important for service users when making decisions about their rights to take risks and understand available options. The statement of purpose and contract are in written format. This may not always meet the communication needs of people seeking information about living in this home The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8 and 9 Development in the care planning system provides adequate information for carers that is if necessary to satisfactorily meet service user needs. Carers have an understanding of the individual risks to service users and are keen to develop their knowledge of risk assessment strategies to further promote the health and well-being of the people living in this home. EVIDENCE: Individual care plans are available and adequately identify all aspects of the health, personal and social care needs of the individual person. The daily living needs of service user is described well; this does not however extend to nightly care needs. Social services have been approached in the development of care plans and the home diary shows that the community care assessment and an annual review for one service user is planned for June 2005. Risks to individuals are described on their care plan. Strategies have been put in place to maintain the safety and well-being of the individual. This includes, using keys, verbal aggression, fire safety and eating and swallowing difficulties. The registered person and carer know these strategies however, they are not recorded on the care plan. A record is being maintained of the specialist consultants supporting the registered provider in meeting specific The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 10 service user needs. This includes psychologists and community learning disability nurses There is some evidence of service users being involved in the care planning process and one service user has been able to sign their care plan. The support of family, friends or advocates in the care planning agreement has not been considered. Appropriate advocacy support will be beneficial to service users in understanding available options and their right to take risks. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 Service uses health-care needs are identified on their care plan and being met with appropriate specialist support. Changing needs are not always recorded on the care plan. Medication is being administered by trained staff. EVIDENCE: Care plans and home records show that care specialists are supporting the staff in meeting service user’s health care needs. This includes psychologists, community learning disability nurses, GPs, chiropodists and dentists. A record of all visits/appointments is made in the home diary and on care plans. Letters from healthcare professionals are maintained on care plans which describe recommendations or changes in care needs. Care plans are not always amended to identify this change. The care needs of the people living in this home are met solely by the registered provider and carer. This is providing considerable consistency for service users in meeting care needs. In the event however of neither carer being available to provide this care it is important that care plans are maintained up to date to provide sufficient information at all times of care needs that may have to be met in an emergency by other carers. The registered provider and Carer have completed a Distance Learning course in the Safe Administration of Medicine to ensure that service users are supported in a safe manner with their medication. Certificates of achievement were available. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There are systems in place for listening to service user concerns by Carers who have a good understanding of the importance of protecting service users from harm. Systems are not in place for the protection of service users from harm in the event of the existing carers being unable to provide care. EVIDENCE: A positive relationship was observed between service users and their carers and discussion at the time of the inspection was being encouraged with service users in agreeing the evening’s activities. Service users points of view were listened to and taken seriously. The complaints policy is available for service users and a copy is with their care plan. A copy of the local authorities vulnerable adults procedure is also available to service users. Both documents are in written format. Service users living in this home however have specific communication needs and this format would not appropriately meet their needs. The documents are not easily accessible to service users, their friends or family. There is documentation in the home for recording complaints, incidents and accidents to service users and vulnerable adult issues. The staff supporting service users demonstrated an understanding of their role in the vulnerable adults procedure and have recently completed Learning Disability Award Framework training which included supporting service user rights and responsibilities and vulnerable adult procedures and practices. This is the family home of the registered provider and the care for service users is solely provided by the registered provider and her partner. Discussion took place with the registered provider regarding the provision of care in an emergency in the event that she and/or her partner would not be available to provide this care. It was explained that the registered providers family would The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 14 provide this care in an emergency. The registered provider however does not have a written emergency plan of care provision that would ensure service users would continue to be cared for safely and protected from harm by the people caring for them. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This standard was not assessed on this occasion. EVIDENCE: The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35 Significant progress has been made in addressing staff training needs and as a result of this service user needs are being appropriately and safely met. The number of staff employed would not be sufficient to meet the individual lifestyle needs for three people living in this home. EVIDENCE: The registered provider and carer have made significant progress in achieving the skills and knowledge necessary in meeting and supporting the needs of the people living in this home. Training certificates have been awarded. This has included completion of the Learning Disability Award framework training, first aid awareness, manual handling and safe handling of medicines. The carer has completed a training course in dementia care, which was necessary to support the specific needs of service users. The registered provider has yet to complete this course. The registered provider and carer are continuing to develop skills and knowledge in the care provision and have made arrangements to complete risk assessment training and enrolled to be assessed towards NVQ 3 from July 2005 There are currently 2 service users living in this home and their identified needs can be sufficiently met by the registered provider and carer. Diary records and care plans show that the service users are accessing lifestyle activities in the community with appropriate support. In the event of another service user however coming to live in the home however the current number The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 17 of staff would not be sufficient to maintain the preferred lifestyle of service users or promote individual choice. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) and 43 The registered person has taken action to access training in risk assessment and to submit a business plan for the home. EVIDENCE: Documentation in the home and discussion with the registered provider shows that it is the intention for risk assessment training to be completed in November 2005. The registered person has approached Solihull Social Services for guidance in developing a business plan for the home. This was documented during the meeting held between the Commission, the registered person and a representative from Solihull Social Services in February 2005. Timescales have been amended and the standard will be assessed further at the next inspection visit. There is documentary evidence to show that the limit on personal insurance cover for service users belongings is set at £2000 per head. A certificate is available in the home to show that the services and facilities comply with the Water Supply (Water Fittings Regulations) 1999. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 19 Requirements and recommendations made at the previous inspection are within agreed timescales and will be assessed at the next inspection visit. The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Hollies Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 2 v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 21 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 1 Regulation 4 Requirement The registered person must ensure that the statement of purpose contains information regarding access to services and facilities in the home, including access to bathroom and firstfloor facilities. The registered person must ensure that service users are offered advocacy support when making decisions and choices. The support can be from family members or friends or through referral to advocacy services. The registered person must ride down a plan of nightly care for the two men living at the home. The registered person must ensure that community care assessments and community care plans for each existing resident are completed. (Previous timescale 1 March 2005) Strategies being used to minimise risk must be recorded on individual care plans and subject to documented review. The registered person must ensure that all changes identified by GPs and other health-care v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Timescale for action July 1 2005 2. 5 12 August 30 2005 3. 4. 6 6 15 14 June 30 2005 July 30 2005 5. 9 13 July 30 2005 July 30 2005 Page 22 6. 19 12 The Hollies Version 1.30 7. 23 13 8. 33 18 9. 37 10 10. 39 24 11. 42 13 12. 43 25 specialists are recorded on the care plan. The registered person must ensure that a written plan of emergency care provision is identified and this must include information and documents specified in Schedule 2 of the Care Homes Regulations for the people identified to provide emergency care have been obtained. The registered person must ensure that sufficient staff are on duty within the home to meet the identified needs of individual service users and to ensure the health and welfare of service users following admission of a third service user to the home. The registered person must complete training in dementia care. (Old timescale March 15, 2005) The registered person must devise a method for quality assurance within the home. Copies of such surveys are to be sent to interested parties including the Commission for Social Care Inspection (Timescale agreed at previous inspection January 1, 2006) The registered person and her partner must undertake training in risk assessment (old timescale April 1, 2005) The registered person must submit a business plan for the home for 2005/06 to the Commission. (Old timescale April 1, 2005) September 30 2005 June 1 2005 September 30 2005 January 1 2006 November 30 2005 September 30 2005 The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations It is recommended that information for service users about the home, (statement of purpose), their rights and responsibilities, (Contract) and how to express their concerns, (Complaints and Vulnerable Adults procedure) is in a format suitable to meet their needs. This can be in a taped format It is recommended that the complaints policy and vulnerable adult procedure document is easily accessible to service users, their family members and friends. This could be in a shared area of the home. 2. 22 The Hollies v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 v231418 e53 s4357 the hollies v231418 240505 stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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