Inspection on 14/05/09 for Holly House

This is the latest available inspection report for this service, carried out on 14th May 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly House 17/11/05

Holly House 13/06/05

Holly House 10/01/05

Holly House 22/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Holly House Greasbrough Road Parkgate Rotherham South Yorkshire S62 6HG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Valerie Hoyle     Date: 1 4 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Holly House Greasbrough Road Parkgate Rotherham South Yorkshire S62 6HG 01709523241 P/F01709523241 NONE Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Patricia Burgin care home 12 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 12 All existing service users may remain at the home after they reach the age of 65 years. Date of last inspection Brief description of the care home Holly House is a home that accommodates 12 people with learning disabilities in the category of younger adults, with some people over 65 years of age. The home is situated in large grounds, which border agricultural land whilst being within a short walking distance of the local shops and facilities of Parkgate. The home is generally run as one unit although there is a semi-independent living section known as the Coach House. There is a mixture of single and double bedrooms and a number of rooms have ensuite facilities. There are large grounds, some of which are grassed and some left for planting. Information gained during this inspection confirmed fees charged are from three hundred and ninety-eight pounds and eighty-eight pence to eight hundred and eighty six pounds. Service Users Guides and Statement of purpose is available from the manager, and the last inspection report dated 6th June 2007 is available on request from the home. Care Homes for Adults (18-65 years) Page 4 of 29 Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that the people who use the service experience adequate quality outcomes. This unannounced inspection took place over 6 hours starting at 10:30 finishing at 16:30; this included a partial inspection of the home. Seven people who use the service, and the deputy manager were spoken to during this inspection;their views are included throughout the report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is Care Homes for Adults (18-65 years) Page 6 of 29 considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Occupancy at the home remains high with 11 of the 12 beds occupied. The deputy manager told us the bed was in a double room and that they do not intend to fill the bed as it is used by a person who does not want to share. Three peoples care plans were looked at. Policies relating to medication, complaints, protection of vulnerable adults and handling of peoples monies were looked at. Three staff recruitment and training records were looked at to assess how people were protected. Procedures and risk assessments relating to health and safety were looked at and discussed with the deputy manager. The manager and registered provider is Patricia Burgin; she has owned the home since 1985 and has the required management qualifications, competencies and skills. The AQAA was sent to the home and was returned to us on time, which demonstrates responsiveness and cooperation. An Annual Quality Assurance Assessments is a selfassessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. The AQAA also provides us with statistical information about the individual service and trends and patterns in social care. The inspector would like to thank everyone who agreed to being interviewed as part of the inspection process, and the friendliness of staff. What the care home does well: What has improved since the last inspection? What they could do better: The service could improve the way they gather the views of people by undertaking yearly surveys for stakeholders and people who use the service. They should provide the outcomes of the service to those who had taken part in the process. Medication Administration Records chart entries should be sufficiently clear and detailed to be sure that all staff can follow the directions and changes correctly. Medication record keeping must be improved so that all medicines entering the home can be fully accounted for. Medication procedures should be improved so that they meet the Royal Pharmaceutical Society of Great Britain and CQC professional advice documents on handling medicines in social care. Arrangement should be made to ensure best interest meetings are held for people identified in this inspection. Staff should ensure they fully understand when it is appropriate to refer incidents to the safeguarding adults team. The refurbishment of the laundry must take place to ensure it is fit for use and safe for people to use. Paint and other substances must be removed as they pose a significant risk to people who use the service. Care Homes for Adults (18-65 years) Page 8 of 29 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are looking to moving into Holly House have their needs and aspiration assessed. Evidence: Assessments were looked at and they contained sufficient information to enable staff to make a judgement on meeting the needs of people. Social Services also undertake an assessment and together the infomation forms the basis of the final care plan. The deputy manager said the process of admissions is at the pace of the individual. People are encouraged to visit the home prior to admission so that they can make informed decisions about the home. People confirmed they were involved in making decisions about moving into the home and one person said the move was very good for him and he enjoys living in Holly House, and has made friends with other people at the home. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to be involved in planning their care. Risk assessments were sufficiently detailed, although some best interests meeting are needed to ensure people can pursue their interests. Evidence: Care plans and risk assessments were looked at including where peoples freedom of movement was affected. The care plans were up to date and reflected the care needs of people. The deputy manager said they had developed a person centred approach and people had been involved in developing their care plan if they expressed an interest to. Daily records were sufficiently detailed to enable staff to evaluate how people were meeting their goals. Recent incidents involving one person has identified the need to hold a best interest meeting using the deprivation of liberty procedures. Other issues discussed with the deputy manager has also identified the need for best interest meeting to ensure Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: people can make informed choices about how they spend their time Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to be part of the local community and take part in appropriate activities. Individuals are supported to maintain relationships with family and friends. Evidence: People were supported and encouraged to take part in activities out of the home. Some go to training centres while others have work placements. One person was going out to their work placement at speak up. The person told the inspector that they enjoyed having very active life. The person attends various work and educational placements throughout the week. People were supported to engage in educational courses including literacy and arts and crafts. Two people attended a pottery class during this inspection and they were happy to show the inspector some of the items that they had made. Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: They are supported to make decisions about social and leisure activities which includes holidays and outings. People held discussions about the type of holiday they wanted to take part in, including a holiday on a barge, and a trip to Blackpool. One person continues to attend a local gym, although the person said they sometimes got fed up of going. Mealtimes are organised to fit in with peoples routing and they have their main meal at teatime. They encourage people to eat a healthy diet and menus are arranged around the likes of people. Care Homes for Adults (18-65 years) Page 15 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health action plans ensure people are supported to attend appointments. Medication policies and procedures were ineffective and could pose significant risk to people as they may not receive their medication as prescribed. Evidence: People were supported to attend medical appointments and hospital consultants visit the home periodically to undertake mental health assessments. Keyworkers ensure people are supported with their health action plans and they assist with meeting personal hygeine and bathing needs. One persons mobility had deteriorated and now occupies a downstairs bedroom. Mobility aids had been aquired to help maintain their independance. People were able to make decisions about the times they get up and go to bed, although their daily routines means that they are usually up in time to catch their transport to training centres. They are encouraged to help with the routines around the home, which includes help with laying tables for meals, tidying their bedroom and assisting with their laundry. Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: Medication procedures were looked at and an audit of the MAR (Medication Administration Records) found serious concerns with the management of medication. Some medicines were not booked in and some had not been signed for but administered. One persons medication did not have a MAR, although the medication had been admisistered for 2.5 weeks. The MAR was found but staff had not commenced using it to record the medication had been administered. A MAR had been broken down into four sections to record a once a week drug, although the stock did not correspond with the record. They do not have any controlled drugs or a medication fridge. There are procedures in place for ordering, receiving, administering and disposing of medicines but these documents do not always follow current best practice. The Royal Pharmaceutical Society of Great Britain and CQC professional advice documents on handling medicines in social care are not available in the home. Care Homes for Adults (18-65 years) Page 17 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were able to express their concerns, and they were aware of the complaints procedure. The home have safeguarding procedures although one incident had not been referred as required by the procedures. Evidence: Complaints and safeguarding procedures were looked at and they confirmed that no complaints had been made since the last inspection. The procedure was out of date and could be made more user friendly, by using easy read and pictures to discribe the procedures. People generally knew how to make a complaint although they said they were happy with their care and did not feel they needed to complain about anything. the home has safeguarding procedures however, one incident involving a person missing from the home should have been reported to safeguarding, this was discussed with the deputy manager. A best interest meeting should be set up to discuss their deprivation of liberty as they have withdrawn the persons bus pass, to prevent further incidents of the person going missing. The home had informed the persons social worker and the Police although this had not been followed up to formalise risk assessments. Staff had undertaken some safeguarding training, although training to ensure staff have a good understanding in the Mencal Capacity Act and Deprivation of Liberty best practise is required for all staff. Care Homes for Adults (18-65 years) Page 18 of 29 Care Homes for Adults (18-65 years) Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was generally clean and tidy however areas in the coach house could be better. The laundry must be improved to ensure it is safe and fit for people to use. Evidence: The environment was generally well maintained although there were areas which needed refurbishment. The coach house bedrooms had a fusty smell leading onto the landing. The laundry area which is used by people was in poor repair and there was tins of paint in the corner of the room. This could potentially be a fire hazard and must be removed and stored correctly. The floor covering needed attention and some of the cupboards were in poor repair. The kitchen is used by service users who assist with preparing snacks. A dishwasher should be purchased to ensure crockery can be sterilised to prevent cross infection. They have fitted a stair lift to the first floor and this is sometimes used by people with poor mobility. The AQAA told us that they will continue to refurbish the home which included a decorating programme. Care Homes for Adults (18-65 years) Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home were skilled and in sufficient numbers to support people who use the service. The home must be clear about the employment status of people placed by a training agency to ensure people are kept safe and protected. Evidence: Recruitment procedures had not been followed on the 3 staff files looked at. The staff were placed by a training agency, which completed a comprehensive induction programme over a ten week programme, while working at the home. The home paid the staffs wages. The deputy manager said the training agency had undertaken the necessary checks, although copies were not available on the files. They had no references although letteres were on file requesting references. They did not have a Criminal Records Bureau checks that had been obtained by the home. Two files did not have application forms or proof of identity. Gaps in employment had not been checked or recorded. The staff were on the rota looked at, although the deputy manager said they were only undertaking escort duties where another member of staff was also on duty. The manager must be clear about the employment status of staff that are placed by a training organisation. They must have documentation to support that the required employment checks have been undertaken and copies must be held on file for inspection. Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: Training was generally up to date and they have above 50 NVQ qualified staff. There was sufficient staff to support people and some of the staff have worked at the home for a number of years. The deputy said rotas have been adjusted to facilitate more support for people to follow their leisure activities. Care Homes for Adults (18-65 years) Page 22 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound health and safety and management practises. People are encouraged to give their views on the service provided although quality assurance systems could be developed further to ensure surveys are used and collated. Evidence: The manager works off rota although it was difficult to confirm if she was in day to day charge of the home. She was unavailable during this inspection, although she was contacted by telephone to enable us to give some verbal feedback about the inspection. The deputy manager holds the required management qualification to manage the day to day operations and she was available throughout this inspection. QA systems were in place although they were dated and the information had not been collated or publicised. The deputy said people were given regular oportunities to give their views on the service, and people confirmed they were happy to give their views about holidays and outings. Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: Health and safety audits take place and accident/incidents were looked at. The deputy was not able to provide evidence that Portable Appliance Testing had taken place as they were waiting for certificate to arrive. Fire records were checked and staff had received fire instruction although refresher training was due. The deputy manager said the fire warden was aware and had started to identify date for staff to attend training. Care Homes for Adults (18-65 years) Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 25 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 Arrangements must be 06/07/2009 made to ensure that accurate records are kept on all medicines received, administered and leaving the home or disposed of. This helps to confirm that medication is being given as prescribed and facilitate accurate checking of stock levels. This will ensure people receive their medication as prescribed. 2 23 23 The laundry area must be cleared of paint and inflamable substances. The flooring needs attention and the cupboard must be replaced. The laundry must be free from clutter. To ensure it is fit for use as it may pose a significant risk to people in the event of a fire 29/06/2009 Care Homes for Adults (18-65 years) Page 26 of 29 3 34 18 The manager must be clear about the employment status of staff that are placed by a training organisation. They must have documentation to support that the required employment checks have been undertaken and copies must be held on file for inspection. 06/07/2009 To ensure the right people are employed to protect people who use the service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 Best interests meetings must be undertaken using the deprivation of liberty procedures. This is to ensure peoples rights can be agreed and formalised. Handwritten entries on the MAR should be accuratley recorded and detailed. This ensures the correct information is recorded so that all staff understand and follow the instructions correctly. Medication procedures should be reviewed to reflect the Royal Pharmacetical Society of Great Britain and CQC professional advice document on handling medicines in social care. Refurbishment of the home should continue to ensure carpets are clean and well maintained to prvent offensive odours. Dishwashing facilities should be improved to ensure crockery etc can be sterilised and prevent cross infection. The home should be clear about incidents that must be referred to safeguarding. Staff must receive training in Mental Capacity Act and the best practise guidance regarding the deprivation of liberty of people using the service. Page 27 of 29 2 20 3 20 4 23 5 6 23 23 Care Homes for Adults (18-65 years) 7 39 Quality assurance systems should continue to be developed and peoples views should be recorded yearly by means of a survey. The results of the surveys should be made available to people. Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 29 of 29 - 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!