Care Home: The Hollies

Similar services:

• Polesworth Group Friary Road
• Polesworth Group Pooley Heights
• Polesworth Group 32 Station Road
• Polesworth Group 70 Long Street
• Breme
• Polesworth Group 64 Long Street
• Polesworth Group 68 Long Street
• 10 Whitfield Avenue

What the care home does well Pre admission assessment are carried out and people who may use the service have the opportunity to visit the home and meet with the staff and people who live at the home before deciding if they wanted to live there. Person centred planning has been introduced and support plans are based upon individual needs. People who use the service are encouraged to be involved in planning their goals and discussing their aims and hopes for the future. We have been told that people who use the service are encouraged to be as independent as they want to be and can be involved with household activities or chores if they choose to. Their views on the day-to-day running of the home are sought at the meetings and discussions they have with their key workers. One person said, "I like to cook and staff have helped me with this, I am also hoping to enrol on a college course." People who use the service access local community facilities and enjoy activities such as pool, going to the theatre, local pubs and shops; some are involved with a local mental health drop in centre and others enjoy socialising with their peers in other services. Relationships with families and friends are supported by the service and a relative confirmed that they have regular contact with the home and are kept informed of significant issues. The service supports people to access health services and works well with health professionals to ensure health needs are met. The procedures for the safe management of medication are robust and records accurately maintained. One person said, "The staff help me with medication and when I go to the doctors." People who use the service say, "I don`t have any complaints about the home, I like living here and my key worker is great, if I had any problems she would help me to sort them out." "I know who to go to and what to do if I have any concerns." Staff have opportunities to attend training courses and the numbers of staff who have achieved or are enrolled on National Vocational (NVQ) training at level 2 is good. Support staff told us that they have the opportunity to meet with a manager on a regular basis to discuss their performance and training needs. The management arrangements at the home are satisfactory and there is evidence that the organisation is monitoring the service and has developed a plan for further improvements to the service. Since we have visited the service we have received an action plan confirming the action they intend to take to address our recommendations. What has improved since the last inspection? At the last key inspection visit we asked that the service take action to improve in a number of areas. The evidence of this visit confirms that these improvements have been made and the service is continuing to develop for the benefit of the people who live there. The service user guide has been updated and produced in a user-friendly format. Person centred planning has been introduced and the service is developing Health Action Plans and 24 hr daily support plans We are told that environmental issues have been made a priority. Areas of the home have been redecorated and we have seen an action plan which identifies all the work that needs doing. People who use the service said, " We have had the lounge redecorated it`s much nicer now." " I have had my bedroom redecorated and a new carpet." Staff training opportunities have improved and there are few vacancies. A new manager has been appointed and a deputy and assistant manager support him. The organisation has introduced a Quality Assurance monitoring team to monitor the services and support them to develop and improve it. What the care home could do better: The service should continue to ensure that the environment is improved for the benefit of the people who live there. There are areas of the home that require upgrading and some furniture and fittings that should be renewed. People who use the service should continue to be supported to live as independently as they want to and to their ability. The service should ensure that all staff have received the training they require to provide a really good quality service. Relevant policies and procedures should be produced in a user-friendly format. CARE HOME ADULTS 18-65 The Hollies 9 Shirley Road Hanley Stoke on Trent Staffordshire ST1 3PF Lead Inspector Wendy Jones Key Unannounced Inspection 26th and 30th September 2008 16:50 The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 1 The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 2 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 3 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Name of service The Hollies Address 9 Shirley Road Hanley Stoke on Trent Staffordshire ST1 3PF 01782 205064 01782 269187 stoke.enquiry@caretech-uk.com 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) Delam Care Ltd Gary Sydney Tideswell Care Home 18 Category(ies) of Learning disability (18), Mental disorder, registration, with number excluding learning disability or dementia (18), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (1), Physical disability (1) The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: 1. 1 Physical Disability (PD) for named person only Date of last inspection 26th September 2006 Brief Description of the Service: The Hollies is a Victorian property located in Hanley close to the local park and the college. It is close to recreational, leisure and shopping community facilities. It is close to a number of other homes owned by the same company and providing services to the same registration category. The home can offer long term care to 18 service users of both sexes that have a learning disability and/or mental disorder. The home offers accommodation on the ground and first floor. The home provides 16 single bedrooms and one double room. The home has two lounges and two dining rooms. The home has one bathroom upstairs and one bathroom with shower cubicle downstairs. The home has an attractive paved area at the rear that provides seating facilities. People who may use the service and their supporters should contact the provider if they need information about the fee range for the service. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection site visit of this service undertaken on 26 September and 30 September 2008. In total the visit took approximately 05:30 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. Since the last key inspection visit of 26 September 2006, we have also completed an Annual Service Review (ASR). An ASR takes place where a service has previously been assessed as providing good or excellent outcomes for people and replaces an annual key inspection site visit. We ask the service to provide us with information about the service’s performance and seek the views of other people, we look at the history of the service and the things they have told us about including any complaints or concerns there have been. The ASR for this service was carried out on 26 October 2007 our judgement at that time was that the service continues to provide good quality outcomes for the people who use the service. This visit included checking that any requirements and recommendations of the previous inspection visit of 26 September 2006 have been acted upon. We looked at information the service provides for prospective service users, their carers and any professionals; looked at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training records, complaints and compliments, fire safety and health and safety checks. The manager, deputy manager, staff, a relative and people who use the service were spoken to during the site visit and a tour of the building was undertaken. Before the visit began, the service provided it’s own assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to people who use the service, relatives, and staff and any professional that has involvement in the service. We received one social worker and one relative survey; the main points are included in this report. Two recommendations from the last key visit have been repeated in this report and we have made further good practice recommendations to be considered. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 7 What the service does well: Pre admission assessment are carried out and people who may use the service have the opportunity to visit the home and meet with the staff and people who live at the home before deciding if they wanted to live there. Person centred planning has been introduced and support plans are based upon individual needs. People who use the service are encouraged to be involved in planning their goals and discussing their aims and hopes for the future. We have been told that people who use the service are encouraged to be as independent as they want to be and can be involved with household activities or chores if they choose to. Their views on the day-to-day running of the home are sought at the meetings and discussions they have with their key workers. One person said, “I like to cook and staff have helped me with this, I am also hoping to enrol on a college course.” People who use the service access local community facilities and enjoy activities such as pool, going to the theatre, local pubs and shops; some are involved with a local mental health drop in centre and others enjoy socialising with their peers in other services. Relationships with families and friends are supported by the service and a relative confirmed that they have regular contact with the home and are kept informed of significant issues. The service supports people to access health services and works well with health professionals to ensure health needs are met. The procedures for the safe management of medication are robust and records accurately maintained. One person said, “The staff help me with medication and when I go to the doctors.” People who use the service say, “I don’t have any complaints about the home, I like living here and my key worker is great, if I had any problems she would help me to sort them out.” “I know who to go to and what to do if I have any concerns.” Staff have opportunities to attend training courses and the numbers of staff who have achieved or are enrolled on National Vocational (NVQ) training at level 2 is good. Support staff told us that they have the opportunity to meet with a manager on a regular basis to discuss their performance and training needs. The management arrangements at the home are satisfactory and there is evidence that the organisation is monitoring the service and has developed a plan for further improvements to the service. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 8 Since we have visited the service we have received an action plan confirming the action they intend to take to address our recommendations. What has improved since the last inspection? What they could do better: The service should continue to ensure that the environment is improved for the benefit of the people who live there. There are areas of the home that require upgrading and some furniture and fittings that should be renewed. People who use the service should continue to be supported to live as independently as they want to and to their ability. The service should ensure that all staff have received the training they require to provide a really good quality service. Relevant policies and procedures should be produced in a user-friendly format. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 9 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 Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who may use the service will receive relevant information about the service in a form they can understand, but do not know what the fee range to the additional costs of the service are. This means they cannot make a fully informed decision about moving into the home. They can be sure that they will receive an assessment and will have an opportunity to visit the home to ensure that they know what it is liked and to confirm that their needs can be met. EVIDENCE: The service told is in the AQAA that, “On receiving a referral to the home assessments are carried out to ensure that the home will be able to meet the needs that are identified. Potential service users are then invited to visit the home and to spend time with both staff and other service users. This will then progress to longer visits and overnight stays. All of this occurs prior to making a final decision on if a placement is to be offered. This allows for a full assessment to be carried out. These visits are vital in allowing the assessment process to be completed fully and to enable it to be used to best effect. This will also determine levels of compatibility with other service users already residing at the home.” One person has been admitted to the service recently, we spent some time discussing the admission and how the individual felt about moving into the The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 12 home. They said, “ I was really nervous, but came to have a look around and the staff were really kind. I was given lots of information about the home and am happy that I have been able to move here.” We looked at information available in care records and saw that the service had received relevant pre admission information and assessments for the individual and had also undertaken an assessment to ensure that they could meet the needs of the person. The service has a Statement of Purpose and a Service user guide, the newly admitted person confirmed that they had been provided with a copy of the guide. We have discussed the contents of the guide with the deputy manager and recommended that the fee range for the service plus any additional costs is included in it. The service has plans to produce the Statement of Purpose in a more user friendly format. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the service has adopted person centred approaches, this means that each individual is supported to take a lead role in setting their goals. EVIDENCE: The service told us in the AQAA that, “The person centred approach that we take to the support we offer allows for individuals like and dislikes to be recognised whether or not they choose to have these documented. PCP documentation had previously been introduced at the Hollies and was attempted with some of the service users although it was felt that this format was not suitable for all. As a result alternative formats are being developed to ensure that all are enable to complete what will become an essential lifestyle plan that is PCP based.” A relative said, “ they are usually very good at keeping me informed of any changes and I am always included with reviews of care.” One person living at The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 14 the home told us, “ my key worker talks to me about support plans and we meet to talk about what I want to do.” Another said, “ the staff have helped me to understand about care plans and I have been involved with making decisions.” We looked at a sample of support plans and have noted that the service has introduced a new person centred format and is working to ensure that all of the people who live in the home have been supported to set their own goals. The sample of records we saw show a very good standard of planning, and risk assessment. The person centred approaches mean that decisions are made in consultation with the individual and in response to their stated needs. Risk assessments are discussed and the evidence of this visit is that people who use the service know and understand why risk assessments are in place. Reviews of care records and risk assessments have been carried out regularly; the staff meet with individuals on a regular basis to discuss their needs. People who use the service know who their key worker is and say that they meet regularly with them and the managers of the home to discuss things that matter to them. Staff should be provided with training and guidance in person centred planning to ensure that they fully understand the principles of it and feel that they can confidently support people who use the service in planning their goals. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they will be supported to access community facilities and have opportunities to be involved in activities of their choice. The development of person centred approaches should ensure that people who use the service are supported to live an independent lifestyle. EVIDENCE: The service told us in the AQAA, “Service users at the Hollies lead an active life with a variety of activities that are available to be undertaken daily. Activity plans are followed should service users wish to do so. All activities are offered are risk assessed generically. Should any activity pose a specific risk to a service user then an individual risk assessment is carried out. Activities are regularly assessed and observed to ensure that the service user is benefiting from the activity.” People who use the service say that they have the chance to go to the pub, the theatre, on trips out and going on holiday. Nine people have been on holiday The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 16 this year and three are planning a trip to Belgium, one person told us about a short break she is going on to Blackpool. A number of people have been on college courses and one person told us that she hoped to enrol on a catering course. Some people access a mental health drop in centre where they can socialise with others, play pool and use the computers. We discussed activities and how people who use the service occupy their time, we saw people living relatively independent lifestyles choosing to go out on their own or with other people, keeping the service informed of their destinations and we are told that there are few restrictions relating to this. People who use the service are aware of their rights to take risks and have been supported to take a responsible approach to risk taking. One person told us, “I enjoy going to the pub in the evening and often meet up with my relative and friends. I have my own key to my room and the front door and can come and go as I want to, but I usually let the staff know where I’m going and what time they can expect me to come back.” People told us that they can be involved with the day to day running of the home, this includes some chores, food preparation and cooking if they want to although the service approach is flexible in this respect. The manager has stated that he is looking to recruit a house keeper to ensure that support staff hours are spent supporting people who use the service to become more independent, rather than completing domestic tasks. A relative told us that, “ They are very good at keeping me informed about things and I usually speak to my relative regularly. I have found though that there have been times I have to check that things have been done properly, this depends who are on duty. But if I speak to them they usually respond positively.” Another relative said, “We are very happy with our son’s progress in life and the care he receives.” Since the last key visit the organisation has introduced a forum, where people who use the services can meet to discuss things that are important to them and raise any areas of concerns. Each of the local services has a representative who attends meetings of the forum. Minutes of these meetings are circulated to the homes. People who use the service told us that they have meetings in the home. We saw the records of these, they are usually arranged monthly. Meals are planned based upon the known likes of the people who use the service and from the ideas they have put forward at the monthly meetings. People who use the service confirmed that they could choose the meals they want to eat and can get involved in preparing and cooking their food if they want to. The service has two kitchens; one is used as the main kitchen, both are functional but in need of upgrading. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will be supported to access the health services they need, this ensures that they remain well. And although medication is properly managed more thought should be given to promoting self-medication and to provide staff with health related training opportunities. EVIDENCE: The service told us in the AQAA that, “privacy and dignity are promoted in all aspects of personal support. All health needs are met in a way that maintains independence. Residents are offered support and guidance in attending regular check ups. Medication needs have been assessed to ensure we can make fully informed decisions about the individuals ability to self medicate.” The service has introduced person centred planning and is also developing Health Action Plans. A Health Action Plan (HAP) is an individual plan, belonging to a particular person that explains what that persons health needs are. It also describes what has to happen for those needs to be met. The service plans to have completed all of the HAP’s with individuals as part of the person centred planning process. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 18 Records show people are supported to attend health appointments and plans are in place to support them, there is regular involvement with health professionals and specialists. We discussed the deteriorating health needs of one person in the service and saw that the service had taken action to ensure that his needs could be met. We understand that people who use the service receive input from specialist health professionals and they have regular reviews of their health and medication with consultants. We have noted from the training information we have been provided with, that all staff who are responsible for the administration of medication have received training to do so and the majority of staff have been trained in emergency first aid. However there is a need to ensure that all staff are trained to meet the needs of the people who use the service this includes training in Epilepsy, diabetes, and mental health. We also recommend that training relating to the needs of older people be provided. Each person has a medication plan and assessment in place relating to risk and promotion of self-medication. Each person has “ how to make choices about medication” file. If they don’t want to self medicate their choice is recorded. A social worker said, “The service sometimes supports individuals to self medicate. In the reviews I have been involved with I do recommend that some individuals are encouraged to self medicate, to promote independence. I also advice that new support plans should be put into place if the individual is self medicating.” There is clear guidance and instruction in place for medication that is prescribed, “As required.” Stock control systems show that good records are maintained and the storage facility is appropriate. Medication Administration Records (MAR) show that medication is being administered as prescribed. A relative commented that the service usually works well with relatives to ensure that they are able to attend appointments but commented that some times communication could be improved; we discussed an example of this during the visit. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they have access to a complaints procedure that is effective and any concerns they have will be listened to and dealt with. Safeguarding procedures provide people who use the service with protection from potential abuse. EVIDENCE: The service told us in the AQAA that, “The complaints policy is clearly on display in the entrance corridor to the Hollies and this enables easy access for service users, their relatives and visitors to the home. A pictorial complaints procedure is also displayed. Any complaints received are logged and dealt with appropriately and promptly to ensure a positive outcome is assured where this is possible. POVA and CRB checks are carried out on new staff and until these are complete they are unable to commence employment. In addition to this two written references are also requested that need to be satisfactory and meet the standards set within out Human Resource team.” We have not received any complaints about this service since the last key visit and are not aware of any safeguarding referrals. We spoke to people who use the service and they confirmed that, “ I’m very happy here I feel safe and know the staff will listen to me if I’m worried about anything.” “ Staff have told me what I need to do if I am unhappy, but I don’t have any problems.” We have been told that people who use the service have the opportunity to raise any concerns at meetings or in the forums that have been introduced. This has been confirmed from the records we have seen. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 20 A relative discussed her experience of making a complaint and said they usually respond promptly, although staff changes have meant, “sometimes for minor things you may have to repeat yourself.” Another relative said in a survey that, “ I know how to make a complaint and the service has usually responded appropriately if I have had any concerns.” A social worker said, “ I have no concerns about the quality of support provided but would like to see the service actively promote independence.” Information in the AQAA states that all staff have received training in safeguarding but this isn’t supported by the staff training records which show that eight staff have received this training. But two staff have been trained to provide training to the staff team and will be doing this. We spoke to one support worker who confirmed that she had received training and knew what to do if she suspected abuse. The organisation has robust recruitment procedures in place and we check their records regularly to ensure that appropriate pre employment checks such as Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) are carried out. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service are provided with a safe and clean environment in which to live but it would benefit from upgrading and redecoration. EVIDENCE: The service told us in the AQAA that, “The Hollies is an imposing Victorian property situated on the outskirts of a picturesque park. It is ideally situated for many amenities, of which our service users enjoy. The house offers both ground and first floor accommodation. The house has two kitchens; a larger one that acts as the main kitchen of the home and a smaller one that acts as a training kitchen for those residents who would like to develop their daily living skills further whilst supervised by staff at the home. All bedroom sizes meet or exceed requirements.” A social worker said, “ I do feel that the interior of the home is quite old fashioned and dated. A lot of the rooms are personalised to the individuals’ taste, which is positive. More rehab is needed.” The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 22 A relative said, “It provides a safe environment for our son, but there is always room for improvement.” The service consists of two Victorian properties that have been converted into one home. All except one bedroom is for single occupancy, the five single bedrooms and the one double room had en-suite facilities. People who use the service said that some people have their own fridges and can make their own drinks in their bedroom. Toilet and bathing facilities are provided in sufficient numbers to meet the need of the people who live at the home. There is evidence of on going improvements in the environment and clearly this has been needed. People who use the service commented on the recent redecoration of the main lounge area and discussed other plans for further development. The deputy manager said that the service is aware of the need to upgrade the environment generally to make it more appealing to the people who live in it. We have been provided with a copy of the plans to improve the environment. People who use the service said, “ I have had my bedroom redecorated and had a new carpet.” “ The living room is much nicer now it’s been decorated.” “I can have what I want in my bedroom and like having my things around me. I have a key to my bedroom door.” The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service are supported by an experienced staff team who are well supported and supervised and have receive training in most areas to ensure that they can deliver appropriate care. EVIDENCE: The service told us in the AQAA that, “All staff are provided with mandatory training and are offered further training to ensure that a good standard of care is consistently provided. CareTech offer a wide and varied amount of training courses that cover all aspects of the work that is done within its homes. Staff at the Hollies are nominated for training following schedules being issued by the training department of the regional office. New starters are subject to a two-week induction period in addition to mandatory training and the LDQ. Staffs are encouraged to take the opportunity to work towards NVQ qualifications to support them in their work and to provide them with additional knowledge and skills that they can then bring to the workplace. At the current time some of the staff team are enrolled on NVQ’s with others due to enrol very soon. The process for recruitment of staff is a rigorous one that ensures staff employed for the Hollies are suitable to the role and that they The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 24 are free from any issues that would prevent them from passing successfully through the CRB process.” A social worker said, “ The care staff usually have the right skills and experience to support individuals social and health care needs and respond to the different needs.” Staff rota’s show that the service usually deploys two support workers during the waking day and has two night staff. The manager provides additional hours. We understand that these staffing numbers are lower than those usually deployed because of staff sickness. The service should ensure that sufficient numbers of staff are deployed at all times. Staff told us that they had completed most of the mandatory training or had been nominated for updates, this includes, infection control, medication, basic food hygiene, fire training and manual handling, and safe guarding up dates are being arranged. Both of the staff on duty said that they are undertaking NVQ level 3. Training records show that there are some gaps in staff training including mandatory. The records show that there are some staff who have not yet received training in some of the mandatory areas required and there are gaps in training in areas that are specific to the people who use the service such as Autism, Mental Health Awareness, Epilepsy, Understanding Challenging Behaviour and None Violent Crisis Intervention. 50 of the staff team have not received safeguarding training and 75 have not received training in Infection Control. A third of the staff have not received training in manual handling or Health and Safety. Seven of the staff have trained to NVQ level 2, one has NVQ level 3, four are enrolled on it. The deputy manager has enrolled on NVQ level 4/Registered Managers Award. Person centred planning training has been provided to all senior staff, the rest of the support staff team should also be offered this training to ensure that they are effective and understand the principles of person centeredness. Staff who are responsible for the supervision of others have competed the necessary training. Staff spoken to confirm that they receive regular one to one supervision sessions where they are able to discuss their progress and training and development needs. The deputy manager stated that supervision is planned monthly. The service currently has 1 staff vacancy and has recently recruited an activity co-ordinator. We did not look at recruitment records during this visit, we have an arrangement with the organisation where the records are checked at the company head office periodically and have been satisfied that recruitment procedures are robust. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the service is well run, monitors the quality of the service provided and acts to continually make improvements. EVIDENCE: The service told us in the AQAA that, “We benefit from having an experienced and enthusiastic manager who is well supported by a deputy and assistant manager. The management team ensure that service users rights are promoted. These rights are safeguarded by the importance placed upon accurate recording and close attention paid to policies and procedures. The home is well run and support is provided to the management team from the area manager. The ethos of the home is clearly described in the home’s statement of purpose and the service users guide. There are robust policies and procedures in place to guide and facilitate staff within their job roles. All staff are able to access them and read them at any time. The home has is visited monthly the area manager. This visit allows her to highlight any areas The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 26 that she feels need attention.” The service has appointed a new care manager since the last key visit he has been approved by us and registered as a fit person. It is understood that he intends to complete the Registered Managers Award this year and enrol on NVQ 4 in care. We have on record, evidence of CareTech’s commitment to support him to do this. People who use the service said, “ I can talk to Gary.” A relative said, “ We feel that care has actually improved since the new manager has been employed.” A Quality review of the service has been carried out and a development plan produced by representatives of the organisation. This plan gives timescales by which the service should address any areas that are identified for improvement. The service has developed methods of ensuring that the views of people who use the service are routinely sought about the quality of the service provided. We did not establish during this visit if the service has acted to seek the view of relatives and other stakeholders, this should be pursued. Information in the AQAA indicates that policies and procedures have been reviewed and that equipment in the home has been serviced. Fire safety procedures are satisfactory and we have received confirmation from the fire safety officer that he is satisfied with current arrangements at the home and has seen a copy of the fire safety risk assessment. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 27 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 3 2 4 3 X 4 3 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 2 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 x LIFESTYLES Standard No Score 11 2 12 3 13 3 14 4 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 3 X 3 x The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 28 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. 5. 6. 7. 8. 9. Refer to Standard YA8 YA22 YA1 YA32 YA24 YA32 YA32 YA33 YA37 Good Practice Recommendations To look at areas where residents could be more involved in aspects of running the home e.g. staff recruitment To develop further policies and procedures in a user friendly formats Include the range of fees for the service in the Service User guide. For staff to receive training in working with people with challenging behaviour, autism, mental health needs and in working with older people. The service should continue to improve the environment in all areas listed in the action plan. For all staff to receive mandatory training, this includes, infection control, safe guarding, moving and handling. For staff to receive training in person centred approaches. The service should ensure that sufficient numbers of staff are deployed at all times. For the manager to complete the RMA and NVQ level 4. DS0000064031.V372026.R01.S.doc Version 5.2 Page 29 The Hollies 10. YA39 To seek the views of relatives and other stakeholders on the quality of service provided. The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands 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 The Hollies DS0000064031.V372026.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!