CARE HOME ADULTS 18-65
The Hollies Church Road Shustoke Coleshill Birmingham B46 2JX Lead Inspector
Sheila Briddick Unannounced Inspection 9th November 2005 09:00 The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 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 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) Mrs Alison Thorneywork Mr Anthony P Shepherd Mrs Alison Thorneywork Care Home 3 Category(ies) of Learning disability (3) registration, with number of places The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The Registered Manager (Alison Thorneywork) completes training in Dementia Care Awareness by 31st October 2005 24th May 2005 Date of last inspection 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 DS0000004357.V264742.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 9 November 2005 between the hours of 9 a.m. and 1 p.m. During this time the inspector had opportunity to meet with the people living in the home and observe the interactions between service users and the people who are caring for them. A tour of the home took place and documents relating to service users and the management of the home were examined. The views of professionals involved in the care service, including the homes GP, have also been sought as part of this inspection. The Condition imposed on the registration of the care home requiring the registered person to complete training in Dementia Care by September 30, 2005 has been met. A certificate of attendance on an appropriate Dementia Care course by the Registered Provider has been seen and this is being held in the care home. What the service does well: What has improved since the last inspection?
Service users have sufficient information about the home and of their rights and responsibilities whilst living there; this information is available on tape format, which meets their communication needs. Care plans were up-to-date and contain sufficient information so that people caring for service users would be able to understand their individual needs, wishes and choices. There are no care staff employed in the home as the Provider and her partner provide 24 hour care and support. The Provider therefore has produced an emergency care provision plan to ensure care can continue to be provided in the home safely in the event of an emergency. The Provider and carer continue to develop links with other professionals in care services and this has included seeking information regarding advocacy services and support.
The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 There is sufficient information about the services and facilities in this home to enable prospective users to make a decision about living there. Terms and conditions of residency are agreed with service users and a written contract is made. EVIDENCE: The statement of purpose has been produced in audio format to enable service users with specific communication needs to understand their rights and responsibilities within the home. The tape is kept in the lounge and therefore easily accessible to them. Contracts on the terms and conditions of the service are held on the service users file and have been signed appropriately by the service user or a family member when applicable. Increase in fees for the service had not routinely been amended on the contract. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. The people living in this home can be sure that their assessed and changing needs, and personal goals are reflected in their care plan through a review system that involves themselves, family member or friend and other care professionals. Risk management could be more robust to ensure that service user’s health and well being is reviewed regularly with them. EVIDENCE: Care management reviews for both service users currently living in the home have taken place since the last inspection. The record of the review shows that family members attended along with other professionals involved in the care provision, which included day service staff and social workers. Service user’s views were sought and included in the written record of the review. One service user when asked if the home was meeting their needs replied ‘absolutely’. Care plans seen were in good order and included the preferred daily routines during the week, at weekends and nighttime of the individual service user. There was documented evidence of the registered Provider taking appropriate action to meet identified needs in the care plan review and this included ensuring service users attended health care services for eye and dental care.
The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 10 Risks to service users in the home have been identified and the Provider and Carer have taken action to ensure that risks are minimised through safe working practice. This includes security of external gates to the main road, which runs past the home, fire safety, slips, trips and falls. Risk assessment documentation was good however three risk assessments seen had not been reviewed for some time. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 16 and 17. The people living in this home have opportunity to live ordinary and meaningful lives appropriate to their needs, which is promoting their rights and responsibilities. Food provision is good and ensures a healthy and well balanced diet for the people living in the home. EVIDENCE: Care plan and diary records show that people have access to local facilities and activities. The home’s situation in a small village limits this to pub lunches however; facilities in the nearest town are accessed regularly for shopping and accessing healthcare services. Service users are accessing local colleges through their day service. The preferred choices of service user’s daily routines during the week and at weekends is clearly identified on care plans. Positive interactions were observed during the visit between service users and the people caring for them. Service users were being involved in discussions regarding the day’s activities and in planning future activities. Service users were comfortable about moving about the home and were doing so freely. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 12 The Provider maintains a record of meals taken and the record shows this is varied and well balanced. Food stocks in the home were in ample supply and reflected against the meal records. Service users are able to make their own drinks and access snacks if they wish and were comfortable about doing so. Service users said that they liked the meals they had. Care plan records show that the Provider has sought the advice and guidance of a dietician when meeting individual dietary needs. Risk assessments have been completed for eating and swallowing difficulties where appropriate. Good practice issues were discussed regarding clarity on care plans of action necessary to maintain service users health and well being when eating. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The healthcare needs of the people living in this home are assessed and met with evidence of local and specialist healthcare services being readily available to them. EVIDENCE: Records are being maintained of service users individual healthcare needs and visits made to healthcare specialists. This includes their GP, psychology services, dentists and opticians. Records show that service users are keeping in good health and relatives have made positive comments about this when they have visited. Action required of the Provider following care management reviews for service users to access optician and dental services has been met appropriately and within agreed timescales. Healthcare risks are monitored well although possible risks to health from livestock, including poultry, and gardening activities have not been discussed with the home’s GP. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users would be protected from harm and continue to receive proper care provision in the event of the Provider and Carer not being able to provide care. EVIDENCE: There is a written plan of emergency care provision to be implemented in the event of the Provider and carer not being available to provide care which ensures that service users would protected from by the nominated relief staff cover. This includes ensuring emergency carers have been checked against by the Criminal Records Bureau, (CRB). The draft copy was seen and shows that Social Services, the Commission for Social Care Inspection and Day Services users will each have a copy of the document. The relief staff team are all well known to the service users. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The environment is a warm, welcoming and homely providing service user with a comfortable place in which to live. EVIDENCE: Service users appeared happy and relaxed in their environment. They are able to access all shared areas of the home and can choose to be alone or with others if they wish. Service user’s bedrooms are decorated and furnished well reflecting their individual choices and interests. Bathrooms and toilets were clean and fresh and meeting needs satisfactorily. There is no identified need for mobility aids or adaptations in the home. There home is close to the village amenities and there is a local bus service to the nearest town, although service users use the Provider’s transport for accessing the community. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 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 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): These standards were not assessed on this occasion. EVIDENCE: The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 17 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 and 42 The Provider and Carer continue to develop the skills and knowledge necessary for the effective management of the service. There is no annual development plan or quality monitoring system for the home, without this the Provider cannot demonstrate success in meeting service user’s aims and objectives. Health and Safety management is good however confirmation of monitoring good practice is not documented sufficiently. EVIDENCE: There is documented evidence to show that the Provider and Carer continue to take steps to develop the skills necessary to meet service user needs and management of health and safety. This includes attendance on a Dementia Awareness course by the Provider and enrolment for NVQ Level 3 in Care, Health and Safety and Risk Assessment certificated courses. The Provider continues to seek guidance on developing a Business Plan and Quality Monitoring system for the home and discussed resources that may be available locally. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 18 Health and safety management in the home and outside environment is generally good. This includes maintenance of a safe environment through safe storage of household chemicals, fire safety, maintenance of electrical and heating equipment, checking hot water temperatures and fridge and freezer temperatures. Records regarding these checks are however not routinely kept. Good practice in health and safety management was discussed and how to access this from appropriate professionals including manufacturers of hazardous chemicals. The outside environment, which is a ‘smallholding’, is accessed by service users who assist in caring for animals and poultry kept by the Provider. This is generally in good order and access is good. The Provider is aware of the possible risks to humans from disease from animals and poultry and seeks veterinary advice as necessary. This must include advice regarding precautionary management of poultry necessary in the event of an outbreak of a ‘Bird Flu’ Epidemic in Great Britain. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 2 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score N/A N/A N/A N/A N/A N/A CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
The Hollies Score X 2 X x Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 x DS0000004357.V264742.R01.S.doc Version 5.0 Page 20 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 2 Standard YA5 YA9 Regulation 5 13 Requirement Any increase in fees must be documented on the service user’s Contract. A documented review of individual risk assessments must take place at least annually or as needs change. The Provider must discuss healthcare protection, including Tetanus immunisation, when living and working with animals with the home’s GP. The Provider must devise a method for quality assurance for the home and this must include a business plan for the home for 2006/07. (Old timescale of 30/11/05 extended) The Provider must seek advice from the Department of the Environment of regarding emergency measures that must be implemented in the event of an outbreak of ‘Bird Flu’ in Great Britain and forward a copy of guidance given in writing to the Commission for Social care Inspection. Timescale for action 30/03/06 30/12/05 3 YA19 13 30/12/05 4 YA39 24 30/03/06 5 YA42 13 15/12/05 The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA17 YA42 Good Practice Recommendations It is recommended that the actual recommended size food be to be cut to as part of managing risk is documented on the care plan. It is recommended that COSHH information is requested from manufacturers of products used in the home. The Hollies DS0000004357.V264742.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leamington Spa Office 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
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