Inspection on 05/12/05 for Holly Hall House

This inspection was carried out on 5th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Hall House 29/08/07

Holly Hall House 23/10/06

Holly Hall House 26/07/05

Holly Hall House 07/09/04

Holly Hall House 20/04/04

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

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

CARE HOME ADULTS 18-65 Holly Hall House 170 Stourbridge Road Dudley West Midlands DY1 2ER Lead Inspector Mrs Cathy Moore Unannounced Inspection 5th December 2005 09:00 Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly Hall House Address 170 Stourbridge Road Dudley West Midlands DY1 2ER 01384 252219 01384 252219 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Select Health Care Limited Teresa Owen Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26/07/05 Brief Description of the Service: Holly Hall House is registered to provide care to 10 service users who have a diagnosed learning disability and fall within the younger adults age range (1865 years). A condition has been approved for the home to provide care to 1 named service user who has a learning disability who is over 65 years of age. Holly Hall House is situated on the main Stourbridge Road in Dudley, it can be easily accessed by public transport. The local public transport enables service users to visit other neighbouring areas and places of interest such as Merry Hill shopping centre and Dudley town. Holly Hall House is a large Victorian traditional domestic type dwelling. It comprises of ten single bedrooms (one with en-suite facilities), two bathrooms, one shower room, five toilets (including the ones available in the shower/ bathrooms) an office, kitchen, laundry, dining room and lounge. Car parking is available at the front of the property and garden areas to the side and rear of the home. The home provides service users with opportunities to develop skills for independence. All service users are encouraged to use suitable community facilities and resources and attend day care facilities or college. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector during 09.00 and 12.30 hours. The inspection was carried out as the second of the homes two routine inspections for this inspection year. Three residents’ and one staff member were spoken to. The deputy manager was involved in the whole inspection process. The inspection focussed on National Minimum Standards that were not assessed during the previous inspection and requirements made following the last inspection. The premises were briefly assessed to include the dining room, one resident’s bedroom, the garden and two bathrooms. Records pertaining to health and safety, medication systems, staff recruitment and selection and supervision were examined. Not all standards were assessed during this inspection, for a full overview of service delivery this report should be read together with the last inspection report dated 26 July 2005. What the service does well: Resident’s observed and spoken to were happy and content. The atmosphere of the home was extremely positive, welcoming, warm and friendly. The dining room had been decorated for Christmas and looked very attractive, residents’ were proud of the room. Record keeping remains to be of a good standard. The home’s environment in respect of decoration, furnishings and fabric is also of a good standard. The home actively encourages and enables residents’ to make choices to how they want to live their lives. Resident independence is also encouraged and maintained. Positive comments were received from residents’. One resident said’ “ I like living here and I like the staff”. Another said,” We can choose what we eat. We help do the shopping and cooking”. One resident commented, “ We go out a lot, we are going to Merry Hill today”. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 6 Staff commented that residents’ are well cared for and that they are encouraged to live their lives as independently as possible. One staff member said;” I love my job. We work as a team”. It was positive that the deputy manager and staff were able to adequately participate in the inspection and know where things were in the absence of the manager who had escorted a resident to hospital. What has improved since the last inspection? 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. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 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 Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Residents’ are supported to take risks as part of an independent lifestyle. EVIDENCE: Two residents’ were spoken to who confirmed that they are supported to make their own decisions. One resident chooses to smoke cigarettes even though this is detrimental to his chronic chest complaint. The resident has been encouraged by staff to stop smoking yet he chooses to continue. A number of residents’ choose to go out independently and they do. The home has a missing persons procedure dated 2002 which does not instruct staff to inform the CSCI of any incidents where residents may go missing. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17. Residents’ rights are respected and responsibilities recognised in their daily lives. Residents’ are offered a healthy diet and enjoy their mealtimes. EVIDENCE: There was evidence available to demonstrate that daily routines are determined by resident choice. One resident said;” l like to get up early. I get up and go to bed when I want to”. Residents’ are encouraged to be independent. A number of residents’ go out alone to the shops, centre or to visit their families. A number of residents’ have responsibility in terms of being at centres or other places at a set time during the week. Residents’ records demonstrated that they have been offered a key to their bedroom door. A number have refused. One resident stated,” I don’t want a bedroom key”. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 11 Part of the inspection took place in the dining room where interactions between staff and resident’s could be observed. The dining room early in the morning is a very busy place. There was on-going interactions and positive ‘banter’ between staff and residents’. Residents’ were observed making requests to staff. Staff were heard giving the residents’ choices. Residents’ have unrestricted access to all parts of the home with the exception of the office when unoccupied by staff and each others bedrooms unless invited to enter. The home has a 4 week menu in operation which offers different dishes which encourage healthy eating. Fresh vegetables and fruit were seen in the kitchen as was fresh milk. Breakfast time is flexible to meet the daily routines of the residents’. A number had their breakfast before 09.00 one had breakfast later. This resident had cereal and toast. The dining room tables were nicely laid with a toast rack on each to enable residents to help themselves. One resident is on a reducing diet, records show some weight loss since she moved into the home. One resident said enthusiastically, “ All food in nice. We can choose”. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Fine tuning of medication systems is required to ensure safety. EVIDENCE: Staff have received medication training form the homes pharmacy provider. It is positive that staff at the present time are working to attain accredited medication training. The home does not carry a lot of stock medication. A valid contract is in place between the home and the homes pharmacy provider. This pharmacy provider carries out regular audits of the homes medication systems. The home has a medication trolley which is stored in the medication room. The trolley is wheeled into the dining room to administer the medications. All medication records had a photograph of the resident attached. Each resident had signed to consent to medications being administrated. Fine tuning is needed in some areas as follows: a number of staff initial gaps were observed on the medication records. Paracetomal for one resident had been prescribed as ‘ take one or two’ tablets, yet staff were not recording how many tablets they were administering at any time. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Residents’ are protected from abuse. EVIDENCE: It is positive that all existing staff have received challenging behaviour and abuse awareness training in the last year. A copy of Dudley Council’s adult protection procedures is available within the home. Staff have signed to say that they are aware of these procedures. In-house adult protection procedures must be reviewed to ensure that they contain up to date information. The manager was off site during the inspection attending to one resident’s acute medical needs. The safe key was not available, therefore residents’ money could not be checked. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Nil No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35,36. Greater attainment of N.V.Q must be achieved to ensure that residents’ are supported by competent and qualified staff. Further development is needed to ensure that residents’ needs are met by appropriately trained staff. Present staff supervision session frequency falls short of the requirements. EVIDENCE: Staff observed during the inspection were polite and respectful to the residents’ in their care. Good positive communication was observed/ heard between residents’ and staff/ staff residents’. Staff spoken to and observed were motivated and interested in their work. Although the majority of staff are working towards N.V.Q awards records revealed that only 3 of the 13 staff have attained this award to date. A training plan / matrix was available within the home. An individual training plan was included on established staff members’ files. It was identified however, that the newest staff members name was not included on the training matrix. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 16 Two staff training files were perused and revealed that these staff this year have received the following training; Health and safety, moving and handling, abuse awareness and fire safety. It is positive that there was evidence to demonstrate that staff are receiving one to one supervision from the manager. A supervision matrix was available to peruse, as were supervision records. Not all staff however, are receiving supervision to the required frequency of 6 times per year. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Generally, residents’ are confident their views underpin self-monitoring and review in the home. EVIDENCE: The home has up to date business plans available within the home pertaining to the home and overall business. Evidence was available to show that satisfaction questionnaires are used for residents and residents. There was little evidence to show formal processes are in place to gain the views of community stakeholders. There was little evidence to show that recent outcomes of resident surveys have been published. The home is working toward Investors’ In People accreditation. The organisation has its own quality assurance/ quality monitoring processes in place. The senior manager carried out monthly monitoring of the home and forwards a written report of their findings to the CSCI. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 2 x x 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Hall House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x DS0000025034.V269333.R01.S.doc Version 5.0 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 12(1)(a) 18(1)(a) Requirement The registered person and manager must forward evidence to the CSCI to demonstrate that the competency of staff has been assessed in respect of monitoring blood sugar levels. This to include new staff. The registered person and manager must update and maintain the example staff signature/ initial list in respect of medications. Timescale for action 15/01/06 2 YA20 13(2) 05/01/06 Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 20 3 YA20 13(2) The registered person and manager must ensure that where there is a choice of dosage for example one or two tablets the number administered each time is recorded. The registered person and manager must ensure that staff sign medication administration charts at the point of administration or use an appropriate code for non- administration. The registered person and manager must ensure that the homes medication policy/ procedures are fully revised. The registered person and manager must ensure that the complaints procedure is amended to include : The CSCI.( Not NCSC) A 28 day deadline for responding to complaints. ( Timescale of 20/08/05 not fully met). 17/12/05 4 YA20 13(2) 17/12/05 5 YA20 13(2) 20/01/06 6 YA22 22(4) 22(7) 20/01/06 7 YA23 13(6) As it was not possible to check residents’ money during the inspection-The registered person and manager must ensure that an independent audit of all resident money and records is undertaken. Evidence that this has been done together with outcomes from this audit must be provided to the CSCI. 10/01/06 Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 21 8 YA23 13(6) 9 YA32 18(1)(a) 10 YA34 13(6)19(2) The registered person and 01/02/06 manager must ensure that all adult protection procedures are reviewed/ revised. This to include the missing persons procedure dated 2002. The registered person must 01/03/06 ensure that staff continue with their N.V.Q training to ensure that the prescribed 50 attainment rate is achieved as soon as possible or by March 2006. The registered person and 05/12/05 manager must ensure that a satisfactory CRB/ POVA list check is received for all staff before they are allowed to commence employment ( CRBs are no longer portable). ( Timescale of 26/07/05 not fully met). No evidence for inspection of CRB/POVA for ( V ). Evidence of CRB/POVA must be provided to CSCI by 17/12/05 The registered manager must obtain the formal codes of conduct and practice issued by CRB on the storage and disposal of CRBs. There was no evidence during the inspection to demonstrate that this has been done. 11 YA34 17(2)19(2) 12/01/06 Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 22 12 YA34 13(6)19(2) The registered person and manager must ensure that at least one of the two required references is obtained from the prospective staff members direct previous employer. ( Timescales of 07/09/05 and 26/07/05 not met). 15/12/05 13 YA34 19(2) 14 YA35 18(1)(a) 15 YA35 18(1)(a) The registered person must ensure that staff continue with their N.V.Q training to ensure that the prescribed 50 attainment rate is achieved as soon as possible or by March 2006. The registered person and 05/12/05 manager must ensure that at least two forms of identity are obtained from each staff member and that these are retained on their staff file. One must be an official document to confirm current address. The registered person and 05/12/05 manager must ensure that all new staff commence on the prescribed induction/ foundation training within the first 6 weeks of their employment. The registered person and 15/01/06 manager must ensure that the night staff member ( V) commences on the prescribed induction and foundation / LADAF training. The registered person and manager must enter night staff member (V) to the training matrix. 10/01/06 16 YA35 18(1)(a) Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 23 17 YA36 18(2) The registered person and 10/01/06 manager must increase staff supervision frequency to ensure that all staff receive 6 sessions in any 12 month period. 18 YA39 24 19 YA39 24 20 YA42 13(1)(c) 18(1)(a) The registered person and manager must ensure that recent outcomes of resident satisfaction surveys are published. The registered person and manager must ensure that questionnaires or other means is used to measure community stakeholder views in respect of the home. The registered person and manager must ensure that training is arranged for all staff who have not to date received the required mandatory training. ( Timescale of 26/08/05 not fully met). 01/02/06 01/03/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations The registered manager should continue with work to achieve the registered managers award. Holly Hall House DS0000025034.V269333.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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