Care Home: Holly Hall House

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What the care home does well What has improved since the last inspection? New carpets have been fitted within the home, a bedroom decorated and a new minibus purchased. A new suite for the lounge was waiting to be delivered on the day of our visit. The manager has been in post for over 6 months and we were informed during our visit that she is in the process of submitting an application for registration. Everyone we spoke to said management of the home has improved. The views of residents with regard to the home were obtained June 2008 and a quality assurance audit completed July 2008. This means the home is checking it provides a service that residents are satisfied with. A record of hot water temperatures has been introduced that demonstrate these are maintained within safe levels. Staff have received first aid and moving and handling training. This helps them support residents safely. What the care home could do better: Behaviour management care plans must contain enough information to ensure people are fully protected. This must include detailed instructions for the administration of PRN medication that is used to control behaviour to ensure this is not used as a chemical restraint. Staffing levels must be maintained to safe levels so that residents are not placed at risk of harm.The Department of Health`s guidance with regard to employing staff without a full CRB must be followed on all occasions. This will offer safeguards to residents. A list of recommendations is located at the back of this report for people to read. CARE HOME ADULTS 18-65 Holly Hall House 170 Stourbridge Road Dudley West Midlands DY1 2ER Lead Inspector Lesley Webb Unannounced Inspection 28th August 2008 08:45 Holly Hall House DS0000025034.V369919.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 Holly Hall House DS0000025034.V369919.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. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Hall House Address 170 Stourbridge Road Dudley West Midlands DY1 2ER 01384 252219 01384 254190 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) Select Health Care Limited Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 2007 Brief Description of the Service: Holly Hall House is registered to provide care to 10 service users who have a diagnosed learning disability and fall within the younger adults age range (1865 years). A condition has been approved for the home to provide care to 1 named service user who has a learning disability who is over 65 years of age. Holly Hall House is situated on the main Stourbridge Road in Dudley; it can be easily accessed by public transport. The local public transport enables service users to visit other neighbouring areas and places of interest such as Merry Hill shopping centre and Dudley town. Holly Hall House is a large Victorian traditional domestic type dwelling. It comprises of ten single bedrooms (one with en-suite facilities), two bathrooms, one shower room, five toilets (including the ones available in the shower/ bathrooms) an office, kitchen, laundry, dining room and lounge. Car parking is available at the front of the property and garden areas to the side and rear of the home. The home provides service users with opportunities to develop skills for independence. All service users are encouraged to use suitable community facilities and resources and attend day care facilities or college. The charges for this home range from £367-£1050 per week. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We carried out this inspection over one day. The home did not know we were coming. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the inspection the home supplied information to us in the form of its Annual Quality Assurance Assessment (AQAA). We also received 8 questionnaires completed by people who live at the home. Information from both these sources was also used when forming judgements on the quality of service provided at the home. People who live in the home were case tracked. This involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: New residents have their needs assessed before moving in. This means the home knows what support is needed to meet their needs. Care plans in the main, inform staff how people wish to be supported. Residents are supported to make decisions about their lives. Residents are supported to lead full and active lives based on their individual needs and capabilities. Residents were happy to speak to us, confirming their enjoyment of activities they participate in. For example one person explained, “I am going to MIND today at 12, go to age concern Wednesday and Friday, on days off out some times on day trips, I go with my mate X who lives here, I love it here”. Residents are supported to plan and prepare meals. All the residents that we spoke to complimented the choice of meals and confirmed they are involved in menu planning. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 6 Residents’ privacy and dignity is respected. Whenever there is a male member of staff on duty during the night a ‘sleep-in’ person who is female is allocated on shift to assist residents who prefer same gender support. All questionnaires completed by residents that were received prior to the inspection state that they have been informed of how to make a complaint about the care provided by the home if they need to. Bedrooms are individualised with personal possessions, photographs and stereo equipment. Colour schemes, décor and furnishings reflect resident’s individual tastes. Infection control standards are good, promoting the wellbeing of residents. What has improved since the last inspection? What they could do better: Behaviour management care plans must contain enough information to ensure people are fully protected. This must include detailed instructions for the administration of PRN medication that is used to control behaviour to ensure this is not used as a chemical restraint. Staffing levels must be maintained to safe levels so that residents are not placed at risk of harm. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 7 The Department of Health’s guidance with regard to employing staff without a full CRB must be followed on all occasions. This will offer safeguards to residents. A list of recommendations is located at the back of this report for people to read. 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. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs assessed before moving in. This means the home knows what support is needed to meet their needs. EVIDENCE: Information from the homes Annual Quality Assurance Assessment (AQAA) with regard to pre-admission processes states ‘to ensure service users are properly introduced into the home, the manager goes to do an assessment on the service user to establish their needs. Before entering the home we arrange visits for the service user to adapt to the new environment, trial stays including lunch or an over night stay. Following the service users visit to Holly Hall House if it has been decided by everyone involved including the service user that they would be happy at Holly Hall on a full time basis then a permanent placement is then arranged. This is carried out in meetings. A letter will be given to the individual to state whether the home is able to meet their needs or not’. Examining the records of the newest person to move into the home and talking to people found this information to be accurate. For example an assessment of need has been completed that covers areas including mental health, involvement in domestic tasks, social interactions, Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 10 health and medical needs. It is from these that specific care plans are generated that inform staff how a person needs to be supported. We noted that the assessment states that the resident came to visit the home on a number of occasions but we could not find records of these visits. It is recommended that detailed records of trial visits to the home be maintained in order that the findings can be incorporated into the assessment of need. We received 8 questionnaires completed by people living at the home. All confirm they were asked if they wanted to live at the home and 7 that they received enough information about the home before deciding if it would meet their needs. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans would benefit from some minor amendments to ensure that all needs are captured. Residents are very much encouraged and enabled to make decisions about their lives and are supported to take risks as part of an independent lifestyle. EVIDENCE: All the residents’ files that we examined contained care plans that inform staff how people wish to be supported. These included plans for personal care, medication, communication, socialising and other identified needs. We found plans have been signed and dated by both the home and the resident, evidencing the residents’ agreement with their contents. We noted that one resident has care planning documentation for absconding that would benefit from being reviewed as different documents contain conflicting information. For example the care plan states if missing for 1 hour the police are to be contacted but the protocol attached states contact after 2 hours and 6 hours. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 12 Another care plan for the same resident for behaviour states if missing for more that an hour or hour and a half police to be informed. We also noted that care plans have been generated for some people for no identified needs. For example care plans for mobility are in place for people who need no assistance in this area. The plans contain almost no information. We discussed this with the deputy and area manager advising that if there is no identified need a care plan should not be in place. Observation of care practices, discussions with staff and residents and viewing of documentation demonstrate that attempts are made to involve individuals when making decisions about their lives. For example the home produces a newsletter that informs people of events including holidays, activities and the environment and regular residents meetings take place that encourage residents to make decisions about the support services they receive. All of the questionnaires returned to us before our visit confirm that people living at the home are supported to make decisions about the lives they lead. As with care planning in the main risk assessments are in place for identified needs. We found some minor omissions and suggested to the deputy that a review of care planning documentation be undertaken to ensure risk assessments are completed for any identified need. This will promote a holistic approach to care management. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead full and active lives based on their individual needs and capabilities. EVIDENCE: We talked to residents, staff, observed practices and examined records and found people lead stimulating and interesting lifestyles. We looked at activity records and these demonstrate that residents attend various day centres, undertake independent living skills and therapeutic activities. For example on arrival at the home residents were getting ready to go out, some to Dudley Zoo, others to day centres and some residents were sitting completing puzzle games. The atmosphere was very lively. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 14 Residents were happy to speak to us, confirming their enjoyment of activities they participate in. For example one person explained, “I am going to MIND today at 12, go to age concern Wednesday and Friday, on days off out some times on day trips, I go with my mate X who lives here, I love it here”. Another resident explained how they are supported to complete independent living skills, “I help with cooking. Do own washing, put gloves on when getting dirty washing, iron with staff watching me”. As at the previous inspection we saw lots of evidence where residents are encouraged to make friendships and maintain links with their families. Residents are supported to plan and prepare meals. All the residents that we spoke to complimented the choice of meals and confirmed they are involved in menu planning. We saw that a menu board is in operation along with a pictorial menu that helps people be aware of what choices are available each day. The deputy explained that residents are encourage to complete the menu board, explaining, “we like our residents to complete menu board themselves, gives feeling of worth”. Records of meals provided demonstrate residents receive balances meals that encourage healthy eating. When looking at the care records we found that some people have nutritional screening tools completed whilst others have not. It is recommended these are completed for everyone in order that effective monitoring of nutrition takes place. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal needs of residents are met safely by the home. EVIDENCE: Observations and examination of records confirm that resident’s privacy and dignity is respected. For example staff were seen escorting individuals to their bedrooms in order that personal care could be given in order not to compromise their dignity. Assessments and care plans contain guidelines for staff regarding individuals’ personal preferences about how they are guided, supported, moved and transferred. Staff rotas detail male members of staff on duty during the night. It is positive that whenever this is the case a ‘sleepin’ person who is female is allocated on shift to assist residents who prefer same gender support. During the inspection we observed all residents to be dressed appropriately for the climate. Staff were seen to ensure clothing was co-ordinated and appropriate for the age of individuals. All of which promotes residents dignity. Evidence indicates that people living at this home have access to a range of specialist community services should they require them. These include Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 16 general practitioners, opticians, chiropodists, speech and language therapists and psychologists. Health care plans were seen to be in place for identified needs such as epilepsy. These would benefit from being expanded to include greater instructions and guidance for staff. All files that we examined contained weight records (meeting a previous recommendation). Medication systems have been much improved, ensuring greater protection to residents. For example policies and procedures have been reviewed with only information with regard to retaining medication if a person is deceased for 7 days needing to be included, medication boxes are labelled and medication records are kept up to date. The home uses a monitored dosage (MDS) system for the administration of medication. All records for medication entering, being administered and returned were found to be in good order. The deputy confirmed that medication competency assessments are completed for staff as part of their induction to the home. It is recommended that the home obtain the CSCI guidance regarding competency assessments and that these are undertaken on a regular basis to ensure their practices are maintained to a good standard. It is also recommended that the temperature is monitored in the medication cabinet to ensure medication is stored in line with manufactures guidelines. We looked at 6 residents medication and found all to be accurate. We did note that for 2 residents who have been prescribed creams the date of opening was not recorded. This should happen in order that the home can monitor it is administered and discarded within recommended timeframes. Several residents have PRN - ‘as and when required’ medication. Protocols are in place for these that have been signed by the manager. It is strongly recommended that the General Practitioners written consent be obtained to ensure these are administered safely. We also advised that when PRN medication is given for managing behaviour a record of this is maintained on the back of the MAR chart that demonstrates it has been given in the persons best interest. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to raise concerns and protected from harm and abuse. Further development of care plans for the management of behaviour will offer greater protection to people. EVIDENCE: All questionnaires completed by residents that were received prior to the inspection state that they have been informed of how to make a complaint about the care provided by the home if they need to. Information in the homes AQAA with regard to complaints states ‘Every service user / relative and staff member has a copy of the complaints policy / procedure, service users also have a pictorial format of it. Complaints procedure is displayed in full view in the home for all visitors to see. There is an open door policy and anyone can approach any staff member with whatever concerns they may have. Staff are aware of confidentiality and are assured any concerns are investigated thoroughly. Staff concerns can be raised in regular supervisions. We have not received any complaints requiring investigation within the last 12 months any smaller issues have been dealt with efficiently by staff to prevent them escalating’. By examining records and talking to people we found this information to be accurate. for example residents confirmed they know how to make a complaint and who to talk to if not happy and records show that residents are regularly asked if they are hapy or not. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 18 When looking at the minuites of a recent residents meeting we found that residents raised concerns regarding a member of staff. We discussed this with the deputy who informed us the person had received a verbal warning and that another meeting has been arranged to investigate this further. We drew the deputy’s attention to the homes disciplinary procedure advising that this is adhered to. We also instructed that the commission should be notified in line with Regulation 37 of the Care Home Regulations 2001 of any allegation of misconduct of staff working at the home. There are a number of safeguards in place to protect residents from abuse including policies and procedures for the protection of vulnerable adults. Some of the people living at the home have behaviour needs. Although care plans are in place some of these do not contain enough information to ensure people are fully protected. For example one residents care planning documentation does not include instructions for the administration of PRN medication that is used to control behaviour. This must be included; giving detailed instructions to staff to ensure this is not used as a chemical restraint. Of the fourteen staff working at the home 7 have received abuse training. It is recommended all staff receive training in abuse to offer greater protection to residents. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live a clean and comfortable environment that encourages independence. EVIDENCE: Holly Hall House is a large Victorian traditional domestic type dwelling. It comprises of ten single bedrooms (one with en-suite facilities), two bathrooms, one shower room, five toilets (including the ones available in the shower/ bathrooms) an office, kitchen, laundry, dining room and lounge. Car parking is available at the front of the property and garden areas to the side and rear of the home. We undertook a tour of the building and found all areas to be maintained and decorated to a good standard. For example bedrooms are individualised with personal possessions, photographs and stereo equipment. It is pleasing to see that colour schemes, décor and furnishings reflect resident’s individual tastes. Since the last inspection new carpets have been fitted within the Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 20 home, a bedroom decorated and a new minibus purchased. A new suite for the lounge was waiting to be delivered on the day of our visit. Infection control standards are good, promoting the wellbeing of residents. There is a small domestic style laundry that has washing and drying facilities that residents are encouraged to use. All were seen to be clean, tidy and dust free. Residents confirmed their approval of the hygiene standards maintained in the home. All 8 questionnaires returned to us before our visit state the home is ‘always’ fresh and clean. The majority of staff working at the home have received infection control training, promoting the wellbeing of residents. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 21 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): 32,33,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the main residents are supported by staff who are trained to meet their needs. Staffing levels do not always meet residents’ needs. Improvements are needed to some recruitment practices to ensure residents are safeguarded from harm. EVIDENCE: Prior to this visit we received 8 residents surveys. 5 state staff ‘always’ treat them well and ‘always’ listen and act on what say. 3 state staff ‘always’ treat them well and ‘sometimes’ listen and act on what say. Additional comments made include ‘the staff try and look after me in the best possible way’ and ‘they teach us how to do things we don’t know and look after me well’. Throughout the inspection we observed interactions between residents and staff and found relationships to be friendly and relaxed. The training matrix details fourteen staff (including the manager), 8 staff holding a National Vocational Qualification (NVQ) level 2 and 3 of these also holding a NVQ level 3. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 22 The matrix details eleven staff having received Mental Capacity Act training and 5 equal opportunities. The deputy confirmed no one has received epilepsy training or person centred care training. We advised that further work be undertaken with regards to epilepsy and person centred approaches to care and support to ensure staff have sufficient knowledge to support people living at the home. We were informed that between 3 and 4 staff are allocated to the morning shift, 3 of an afternoon and 1 during the night (unless this is a male worker then a sleep in person is also put on shift). The manager is not supernumerary. We viewed the staff rota for 08/08/08 to 04/09/08 and found on many occasions the staffing levels have not been maintained to the stated numbers. For this time period 5 morning shifts were reduced to 2 staff and 21 afternoon shifts also to 2 staff. This is not acceptable as it places residents at risk of not having their needs met safely. We instructed the deputy that staffing levels must be maintained to safe levels. We looked at the staff files for the 2 newest people to commence work at the home in order to see if the homes recruitment and selection practices safeguard people living at the home. Both contained an application form and suitable written references. Both also contained an enhanced Criminal Record Bureau disclosures (CRB) but for one person this has been obtained after they commenced working at the home. There was a PoVAfirst on this person’s file but no risk assessment or evidence of an allocated supervisor (as recommended by the Department of Health). This person is also allocated to undertake night shifts where they work by themselves. We discussed this with the deputy explaining that this person must not work in isolation until receipt of a satisfactory CRB and the Department of Health’s guidance with regard to employing staff without a full CRB must be followed on all occasions. This will offer safeguards to residents. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the main management of the home ensure resident health and safety is promoted. EVIDENCE: The manager has been in post for over 6 months and we were informed during our visit that she is in the process of submitting an application for registration. The manager was not present during our visit however everyone that we spoke to was positive about the management of the home, praising the manager and her style of management. The deputy who was on duty during our inspection demonstrated knowledge and understanding of her role as well as a commitment to providing a quality service to people living at the home. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 24 Quality assurance systems continue to be implemented. This includes a number of quality audit checks including medication, health and safety, resident consultation and the environment. From these action plans are devised. The views of residents with regard to the home were obtained June 2008 and a quality assurance audit completed July 2008. A random sampling of records during the inspection confirmed in the main appropriate action is taken to manage health and safety. Since the last inspection a record of hot water temperatures has been introduced that demonstrate these are maintained within safe levels and insect repellents have been fitted in the kitchen (although this was not working on the day of our inspection). A requirement was made at the last inspection to ensure that night staff receive first aid and moving and handling training. This is now met, with 14 staff having received first aid and 9 moving and handling. In addition to this 12 staff have received health and safety, 12 fire and 11 food hygiene. This ensures residents are supported by suitably qualified staff. Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 33 2 34 2 35 2 36 X 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 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X X X Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA23 Regulation 13(4)(6) Requirement Behaviour management care plans must contain enough information to ensure people are fully protected. This must include detailed instructions for the administration of PRN medication that is used to control behaviour to ensure this is not used as a chemical restraint. Staffing levels must be maintained to safe levels so that residents are not placed at risk of harm. The Department of Health’s guidance with regard to employing staff without a full CRB must be followed on all occasions. This will offer safeguards to residents. Timescale for action 01/10/08 2 YA33 12(1) 01/09/08 3 YA34 19 29/08/08 Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 27 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 YA4 YA6 Good Practice Recommendations Detailed records of trial visits to the home should be maintained in order that the findings can be incorporated into the assessment of need. The resident who has care planning documentation for absconding would benefit from having this reviewed as different documents contain conflicting information. If residents do not have an identified need a care plan should not be in place. A review of care planning documentation should be undertaken to ensure risk assessments are completed for any identified need. This will promote a holistic approach to care management. Nutritional screening tools should be completed for everyone in order that effective monitoring of nutrition takes place. Epilepsy care plans would benefit from being expanded to include greater instructions and guidance for staff. That the home obtains the CSCI guidance regarding competency assessments and that these are undertaken on a regular basis to ensure their practices are maintained to a good standard. That the temperature is monitored in the medication cabinet to ensure medication is stored in line with manufactures guidelines. The date of opening should be recorded on prescribed creams in order that the home can monitor it is administered and discarded within recommended timeframes. It is strongly recommended that the General Practitioners written consent be obtained for PRN protocols to ensure these are administered safely. When PRN medication is given for managing behaviour a Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 28 3 YA9 4 5 6 YA17 YA19 YA20 7 YA23 record of this should be maintained on the back of the MAR chart that demonstrates it has been given in the persons best interest. The commission should be notified in line with Regulation 37 of the Care Home Regulations 2001 of any allegation of misconduct of staff working at the home. It is recommended all staff receive training in abuse to offer greater protection to residents. Further work should be undertaken with regards to epilepsy and person centred approaches to care training to ensure staff have sufficient knowledge to support people living at the home. 8 YA35 Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holly Hall House DS0000025034.V369919.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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