Care Home: Hollywell House

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What the care home does well Hollywell House provides a person centred service. The service provides an individual lifestyle for each of the people living there. The involvement of people in planning their support is good. People who use the service stated that is was a good place to live and were very proud of their home. We were also able to speak to some people who had not engaged in conversation with us on previous visits. This is an example of the relaxed atmosphere of the home and that people living at the home are confident to chat with visitors. The service has a person centred ethos and is run for the benefit of the people who live there. The atmosphere in the home is very relaxed and we observed the informal relationships between the people who live at the home and the staff team. What has improved since the last inspection? The implementation of the medication procedures has improved since the last site visit. The home now has accessible bathroom facilities on the ground floor. What the care home could do better: The home should monitor systems in place to ensure they are fully implemented and working effectively i.e. recruitment, records for training. The Statement of Purpose and Service User Guide should be reviewed to ensure they are up to date. CARE HOME ADULTS 18-65 Hollywell House 63 Clevedon Road Weston Super Mare North Somerset BS23 1DD Lead Inspector Nicola Hill Unannounced Inspection 13th November 2007 09:30 DS0000061655.V352139.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 DS0000061655.V352139.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. DS0000061655.V352139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollywell House Address 63 Clevedon Road Weston Super Mare North Somerset BS23 1DD 01934 629658 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) Hollywellhouse@aol.com Mrs Olabisi Mojibade Hill Mrs Olabisi Mojibade Hill Care Home 9 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places DS0000061655.V352139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 8 persons aged 18 - 64 with learning disabilities and 1 person aged over 65 years with learning disabilities. 6th May 2006 Date of last inspection Brief Description of the Service: Hollywell House is a small community home for people with learning disabilities. It is near local shops and amenities. DS0000061655.V352139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection of the home was undertaken with Bisi Hill, the service provider and manager for Hollywell House. We also spoke with four of the people living at the home, and the staff who were on duty. We looked at the records held at the home and used resident surveys to gather information about Hollywell House. An AQAA had been completed and sent to the Commission, this was discussed with the manager as part of the inspection process. The overall assessment is that Hollywell House provides a good level of service to the people who live there. What the service does well: What has improved since the last inspection? The implementation of the medication procedures has improved since the last site visit. The home now has accessible bathroom facilities on the ground floor. DS0000061655.V352139.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. DS0000061655.V352139.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 DS0000061655.V352139.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): 2,5 Quality in this outcome area is good. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide need to be reviewed so that the information in them is current and up to date. Since the last inspection there has been no admissions to the home. However, historically the home has a good procedure for assessment and admission of new residents. We were shown by the manager evidence of preadmission information she had obtained for a potential resident. This demonstrated that the manager and other professionals were working together to facilitate a comprehensive preadmission assessment and to identify the agreed outcomes of the admission. The manager of the home also takes into consideration the overall service provision and needs of the current resident community before proceeding with admissions. DS0000061655.V352139.R01.S.doc Version 5.2 Page 9 Contracts between the people using the service and the home were in an accessible format, signed and kept in care files. The home currently has eight people living there; their age range is 29 to 71; people confirmed that they were able to attend religious worship of their choice. DS0000061655.V352139.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 good. The service involves individuals in the planning of care that affects their lifestyle and quality of life. Individuals are encouraged to make their own decisions and choices. The care plans are person centred and are agreed with the individual. The plan is written in plain language, is easy to understand and looks at all areas of the individual’s life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the individual planning for the day-to-day care plans and risk assessments for the people living at the home. We noted that the information contained within these documents was very detailed and that risk assessments demonstrated that the home supports people to take responsible risks to DS0000061655.V352139.R01.S.doc Version 5.2 Page 11 explore different opportunities within their lives In order that people can go out into the community and access facilities on a regular basis the home produce a risk assessment with suitable control measures in place i.e. use of taxis to ensure that the people can travel safely. We discussed how people make decisions about their lives and how staff support them with their decision-making. We were able to read and confirm with the people who use the service that they have individual care planning and an individual programme of support. The evidence from the written documentation was that the plans are based on the activities of daily living. There was evidence that the care plans are reviewed at regular intervals. DS0000061655.V352139.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 good. The service has a strong commitment to enabling people who use services to develop their skills, including social, emotional, communication, and independent living skills. People who use the service have the opportunity to develop and maintain important personal and family relationships, and are able to access information and specialist guidance. The staff promote individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection there were eight people in residence at the home. They were made aware of the visit and had the option to speak with us. People were happy to talk with us and discussed aspects of their daily life at Hollywell DS0000061655.V352139.R01.S.doc Version 5.2 Page 13 House. People have a full timetable with varied daytime and evening activities as well as being able to practise their household skills. People living at Hollywell are offered the opportunity to take part in leisure activities; educational activities and the home support workers are able to support people on holidays. Some of the people living there also access to day centres. We spoke with one person who was quite independent and able to access the community without support. They were able to confirm to us that they followed their chosen lifestyle, and were enabled to attend the church of their choice. They spent sometime speaking with us and showing us some of their personal possessions. The manager was able to demonstrate that she used additional staff on evenings and weekends so that the people using the service can get out into the community at any time. We were able to observe throughout the site visit that the people who live there were in and out of the house attending different activities through the day. One person was able to tell us that they were going out with their relative for the afternoon. Friends and relations were allowed to visit or phone; if necessary the home can provide transport to facilitate contact, people can also go home to families for weekends. The menu at the home is designed to take into account expressed preferences. People are offered choices which take into account their activity for the day and the season. People are supported to make their own hot drinks and snacks if possible, and this is part of the developmental process towards independence. DS0000061655.V352139.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 good. Personal support is responsive to the varied and individual needs and preferences of the people who use services. The delivery of personal care is individual and is flexible, consistent, reliable, and person centred. People who use services have access to healthcare and remedial services, staff make sure that those residents who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. People who use services have the aids and equipment they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Generally most people are self caring and require prompts rather than direct care. The personal care support at the home is gender specific and the management ensure that the staff gender mix always reflects the personal preferences of the people who live there. If someone is unwell then there is staff support available to him or her. DS0000061655.V352139.R01.S.doc Version 5.2 Page 15 Since the last visit there has been no change in the way the home accesses primary health care services on behalf of the people who live there. The home continues to benefit from the support of the local health and learning disabilities teams as well as the consultant psychiatrists who are accessed for expert advice. Health action plans have not been fully implemented but there are good records of the visits made to health care providers. The records detail the action needing to be taken to support the person with their health care. One person was able to discuss their recent experiences with the physiotherapy service that had visited the home to assess and support their mobility. There is a unit dosage medication system in use at the home; the records and stock levels of medication were checked and found to be correct. DS0000061655.V352139.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. The service has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. Residents and others involved with the home understand how to make a complaint and are clear about what will happen if a complaint is made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints procedure, which is accessible to the people using the service. People are supported to raise any concerns or issues. The majority of the people living at the home also have relatives who are able to raise issues on peoples behalf. All of the people living at the home are able to communicate in some way so that staff will be aware if they are unhappy. We looked at the complaints record and were able to see that no complaints had been recorded. The staff at the home have all attended abuse awareness training as part of their induction process, this is supported by attendance at Safeguarding Adults training which is updated on a regular basis. DS0000061655.V352139.R01.S.doc Version 5.2 Page 17 DS0000061655.V352139.R01.S.doc Version 5.2 Page 18 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. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet the needs of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The house is well maintained and provides a safe environment for the people who live there. We toured the house and observed that it was clean and tidy. The people living at the homes have large rooms, which they are encouraged to personalise and use as their own personal space. One person was waiting for delivery of new furniture, which would provide better support for them. Suitable facilities are provided for washing personal clothes. DS0000061655.V352139.R01.S.doc Version 5.2 Page 19 The manager has installed an accessible bathroom on the ground floor. We noted that some of the paintwork on the grab rails was flaked and required repainting. For those people who live at Hollywell House who smoke, there are arrangements made for them to smoke outside the house. DS0000061655.V352139.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. There are consistently enough staff available to meet the needs of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although the home has an established recruitment procedure it was evident from reading the documentation in staff files that for two of the support workers this process had not been followed. We noted that both staff were related to people working at the home and so the full process had not been completed i.e. an application form had not been completed and references had not been taken up. However, for the third new member of staff, the complete process had been followed. This was raised with the manager who took immediate action to rectify the mistake. All of the staff at the home have completed POVA first and CRB checks. The training records for staff were up to date and it was difficult to assess if staff had completed their statutory training updates. However the manager was able to use the diary to cross reference the dates for training courses and DS0000061655.V352139.R01.S.doc Version 5.2 Page 21 who had attended with the staff rotas. We were able to read that staff had received training for manual handling, fire safety, basic first aid and food hygiene. Staff are also offered the opportunity to work toward NVQ qualifications. The staff rota indicated that there were sufficient staff on duty to support the three people currently living at the home. The people living at the home confirmed that there were enough people to support them to attend an activities or appointments. DS0000061655.V352139.R01.S.doc Version 5.2 Page 22 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 good. The manager has a clear understanding of the key principles and focus of the service. She works to continuously improve services and provide an increased quality of life for residents with a strong focus on equality and diversity issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service provider, Bisi Hill, continues to manage the home, we observed that the interactions between her and the staff team were good, with an open style of management. She is also directly involved in the care and support to people who use the service, and has a good understanding of their needs. The relationship between the management and the people who use the service was DS0000061655.V352139.R01.S.doc Version 5.2 Page 23 observed to be informal with people accessing the office areas freely. The manager has undertaken training in the last year in areas such as managing challenging behaviour, in order to develop her knowledge and improve the service for the people living at Hollywell House. We discussed how she was able to demonstrate the quality of the service provided to the people who live at the home. She has recently completed the Commissions’ Annual Quality Assurance Assessment. We discussed what information should be included and reiterated that it is a direct assessment against the National Minimum Standards and that the evidence in the assessment should be all of the work the home does to meet the standards. We also discussed how the day to day running of the home worked and what evidence supported this. The people living at the home have meetings and are directly involved in any review meetings related to their support. We were also able to read very positive comments from people who live at the home, in the responses to the surveys sent out by the Commission. Since the last visit a deputy manager has been appointed, who will have supervisory tasks delegated to them. The last visit did not highlight any areas of concern relating to the implementation of health and safety at the home. We were able to read from the information provided that risk assessments and control measures to maintain a safe environment for both staff and people using the service are in place. We were able to read the fire safety procedures had been maintained; PAT had been undertaken; manual handling advice was available and universal infection control measures were in place. DS0000061655.V352139.R01.S.doc Version 5.2 Page 24 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 X 5 3 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000061655.V352139.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 3 4 Refer to Standard YA1 YA24 YA39 YA35 Good Practice Recommendations The service users guide and statement of purpose should be regularly reviewed. Recruitment procedures must be applied to all of the people working at the home. The home must develop a quality monitoring system to show that it’s systems and procedures work to benefit people’s lives. Staff training records must be kept up to date. 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