Inspection on 18/01/08 for The Hollow, Chetan Park

This inspection was carried out on 18th January 2008.

CSCI found this care home to be providing an Adequate service.

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 Hollow, Chetan Park 08/01/09

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Argyll House

Coopers Mill Ltd

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

CARE HOME ADULTS 18-65 The Hollow, Chetan Park 11 School Road Marshland St James Wisbech Cambs PE14 8EY Lead Inspector Andy Green Unannounced Inspection 18th January 2008 11:00 The Hollow, Chetan Park DS0000070495.V358455.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 Hollow, Chetan Park DS0000070495.V358455.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 Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollow, Chetan Park Address 11 School Road Marshland St James Wisbech Cambs PE14 8EY 01945 430934 01945 430906 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) Swanton Care and Community Ltd vacant post Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service: Care Home - PC to service users of the following gender: Both Whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding Learning Disability or Dementia - Code MD Learning Disability Date of last inspection N/A Brief Description of the Service: The Hollow, Chetan Park is a detached property situated in Marshland St James, which is a Fenland village near to Wisbech. The home provides care and support for 4 residents with either mental health needs or a learning disability. The accommodation comprises 4 ensuite bedrooms, lounge, kitchen, wc, laundry and gardens to the rear of the premises. There is a car parking area at the front of the building. The weekly charges range from £1597.36 to £1755.26 Copies of CSCI reports will be made available to residents. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. CSCI carried out this unannounced key inspection on 18th January 2008. The inspector met with the acting manager. This was the first inspection of the home since it was registered in August 2007. The home completed an AQAA (Annual Quality Assurance Assessment) but CSCI did not receive surveys from residents, staff and relatives regarding their comments about home. A variety of procedures and policy documents were inspected including assessment/care planning, the medication policy, staff files, health and safety policies and complaints and safeguarding adults. A tour of the building was also undertaken. Discussions were also held with a member of care staff and one of the residents. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that the care plans and associated risk assessments are completed so that staff have clear guidelines regarding the care and support that residents require. A wider range of activities must be implemented to ensure that residents needs can be appropriately met. Arrangements must be in place to ensure that staff are regularly supervised. Arrangements must be in place to ensure that records of the regular testing of fire alarms and emergency lighting are accurately kept to ensure that residents are protected from harm. It is recommended that the assessment process needs to be developed to ensure that the home receives adequate details prior to admission. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 6 It is recommended that the area, in the office, near to the medication storage cabinet is kept clear so that administration can be safely managed. 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 Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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 Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An assessment process is in place but needs improvement to ensure that the home receives adequate details prior to admission. EVIDENCE: The home has a Statement of Purpose, which needs to be amended as it still shows the previous acting manager’s details. The acting manager and the senior support worker usually carry out assessments. Assessment details were seen in two care plans and gave sufficient background details. Both residents were referred from a home in the same organisation and were admitted to the home in December 2007. It was unclear how much both residents had been involved in moving to the home It is recommended that the assessment process needs to be developed to ensure that the home receives adequate details prior to admission. This was evidenced in a recent referral where additional information would be required regarding the person’s challenging behaviour. Visits to the home and an overnight stay are encouraged where possible as part of the assessment process. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 9 The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to be in sufficient detail to meet assessed needs. EVIDENCE: Two care plans were seen. One contained only minimal amounts of information and the other care plan was still to be completed. Although both residents have only been in the home for a few weeks staff are still assessing needs. Information from the previous placement gave some guidelines but the home must ensure that the care plans and associated risk assessments are completed to ensure that staff have clear guidelines regarding care and support that is required. Detailed daily notes were in place, which included entries regarding activities, healthcare issues/appointments and any other significant events occurring during the resident’s day. The acting manager stated that both care plans would be completed within seven days and evidence of this would be forwarded to CSCI. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 11 The acting manager has subsequently evidenced that the care plans are now complete including accompanying risk assessments. Residents receive adequate healthcare and contact with GPs were evidenced in daily notes. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have limited access to activities in the home and wider community. EVIDENCE: Residents have access to a limited number of activities in the home. The home has the use of a minibus and day trips to local places of interest have been organised. Wider ranges of activities need to be implemented to ensure that residents needs can be appropriately met. Residents have the use of a communal lounge, which includes television and DVD. There is a range of board games and one resident was engaged in a game of Scrabble with a member of staff. As the home is situated in a very rural environment there are few local amenities. The situation may suit residents who prefer a quiet setting but may pose difficulties for residents who prefer to live in a busier environment with access to local towns and facilities. One resident spoken to stated that he did The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 13 not like living in the home as there was little to do and he would prefer to live in a town. A variety of meals are provided in the home and residents are involved with shopping and encouraged to participate in food preparation as much as possible. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The guidelines in care plans need to be improved to ensure residents needs can be safely met. EVIDENCE: All residents are registered with a GP and health concerns are dealt with appropriately and recorded in daily notes and care plans. Staff accompany service users to hospital and GP appointments as required. The resident files seen showed that health care services are available to ensure that residents receive appropriate health and social care from a variety of professionals. Observations throughout the day showed that the communication between staff and residents were friendly and sensitive. It was observed that one of the residents is often very disorientated and during the inspection it was evident that he had become agitated and verbally abusive, as he was unsure where his room was. Staff were observed to assist him in a positive and sensitive manner to reduce his confusion. However there were no guidelines in place to inform staff regarding the steps to take regarding this frequent issue. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 15 Medication records were accurate. It is recommended however, that the area in the office, near to the medication storage cabinet, is kept clear so that the administration of medication can be safely managed. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints process is in place to ensure that resident’s concerns are appropriately dealt with. EVIDENCE: The home has a complaints policy in place to ensure that residents would have any concerns or issues appropriately dealt with. The home has not received any complaints since it has been registered. A complaints logbook is in place. The acting manager stated that ongoing training regarding Safeguarding Adults is provided by the organisation. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of accommodation suitable to the needs of residents. EVIDENCE: The home is decorated and furnished to a good standard. There is a wellpresented lounge incorporating a music system and television. A kitchen and dining room are adjacent to the lounge. There are four well-decorated and furnished bedrooms all with ensuite facilities. The acting manager stated that residents are encouraged to personalise their bedrooms to meet their own preferences and redecorate them if they so wished. There is a large established garden to the rear of the property. The acting manager stated that residents would be encouraged to be involved in gardening projects if they wished to. The office area is in need of reorganising as there was a large number of cleaning products and boxes being stored which need to be moved to a The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 18 suitable locked area. The acting manager stated that this would be attended to immediately. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment and training processes ensure residents are safely supported. Supervision of staff needs to be improved. EVIDENCE: There are two twelve-hour shifts with two staff on each shift to provide 24hour support for the current two residents. The acting manager stated that staffing would increase as more residents are admitted to ensure that needs can be appropriately met. It is also anticipated that the acting manager will be working a 9-5 shift each day and offer personal care and support where required along side the day to day management requirements. Three staff files were seen and they contained the appropriate documentation including POVA/CRB checks, application form and two references. The organisation provides an ongoing training programme including mental awareness, learning disability awareness, managing aggression, The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 20 moving & handling, fire safety, first aid, food hygiene and infection control. A staff member confirmed that the training he had received had been suitable for his needs so far. A programme of NVQ training is underway in the home and the senior support worker is due to commence NVQ 4 in the next few months. Although staff stated that they felt supported by the management formal recorded sessions need to be implemented in accordance with the National Minimum Standards. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 21 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): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are adequate management arrangements in the home. EVIDENCE: The home has an acting manager who provides management support on two days per week. The senior support worker carries out the daily running of home with the support worker team. It is anticipated that the manager’s post will be resolved in the next few weeks. The acting manager stated that he would continue to provide ongoing support during this period of transition. There are contracts in place for the maintenance of the fire system and electrical systems. However, improvements must be made to the fire testing processes in the home including the alarms and emergency lighting as records showed that The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 22 tests had been infrequent. The acting manager stated that testing would be improved immediately. The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 23 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 2 2 2 3 X 4 X 5 X 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 3 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 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 3 3 X 3 X X 2 X The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? No. 1 Standard YA6 Regulation 15(1) Requirement The home must ensure that the care plans and associated risk assessments are completed so that staff have clear guidelines regarding the care and support that residents require. Timescale for action 31/01/08 2 YA12 18(2)(m) 3 4 YA36 YA42 Wider ranges of activities need 30/03/08 to be implemented to ensure that residents needs can be appropriately met. 18(2) Arrangements must be in place 30/03/08 to ensure that staff are regularly supervised. 23(4)(c)(v) Arrangements must be in place 29/02/08 to ensure that records of the regular testing of fire alarms and emergency lighting are accurately kept to ensure that residents are protected from harm. 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 YA2 Good Practice Recommendations It is recommended that the assessment process needs to be developed to ensure that the home receives adequate details prior to admission. It is recommended that the area in the office near to the medication storage cabinet is kept clear so that administration can be safely managed. DS0000070495.V358455.R01.S.doc Version 5.2 Page 25 2 YA20 The Hollow, Chetan Park The Hollow, Chetan Park DS0000070495.V358455.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aylesbury Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR 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. 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