Inspection on 01/05/07 for Holly House

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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 12/01/09

Holly House 20/02/06

Holly House 15/09/05

Holly House 09/03/05

Holly House 18/08/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Holly House Holly House Hall Lane Houghton-le-spring Tyne And Wear DH5 8DA Lead Inspector Irene Bowater Unannounced Inspection 1st May 2007 10:00 Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly House Address Holly House Hall Lane Houghton-le-spring Tyne And Wear DH5 8DA 0191 512 1652 0191 512 6179 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) European Services for People with Autism Limited Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th February 2006 Brief Description of the Service: Holly House is a care home owned by European Services for People with Autism Limited (ESPA), which is a registered charitable organisation. It provides accommodation with personal care and support for up to eight men and women aged between eighteen and sixty-five who have autism specific disorders. Nursing care cannot be provided. The property is a large Victorian villa with spacious decorated and furnished shared areas. It has seven single bedrooms and also a semi-independent living flat, which is on the top floor. Another more modern detached house in the same grounds is used for daytime activities and there are large, well-kept enclosed gardens. Near to the centre of Houghton-le-Spring, the home is close to local shops, Churches and pubs and enjoys good public transport links. Service users also have use of a private vehicle. Each person has different and diverse needs. Both Social Services and the Health Authority carry out funding for each person on an individual basis. Fee rates range from £1,098.62 to £1,731.56. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 28 February 2006. • How the service dealt with any complaints & concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff & other professionals The Visit: An unannounced visit was made on 1 May 2007 During the visit we: • talked with people who use the service and the staff • looked at information about the people who use the service & how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills & training to meet the needs of the people they care for • looked around the building to make sure it was clean, safe & comfortable • checked what improvements had been made since the last visit We told the person in charge what we found. What the service does well: The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. The care plans are detailed and easy to understand. Staff often talk with other professionals to ensure residents health care needs are met. With support of the staff people are able to choose how to spend their leisure time both in group and one to one activities. There is a warm and friendly atmosphere in the home and the staff are experienced and work together as a team. The staff are very clear about their roles and put a huge about of effort into making sure the home is run in the best interests of the people who live there. There are choices for all meals that are nutritious and well prepared. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 6 The home has plenty of staff and they are properly trained so that peoples needs can always be met. Risk assessments are in place so that people are protected as far as possible. Proper checks are carried out before staff are offered a job at the home to ensure the safety and well being of residents. Six surveys were returned to the Commission from relatives. Five offered no concerns about the service. Comments included: I am very happy with the staff and care they give to my relative. Five said they were satisfied with the overall care and had never had to complain. 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. The summary of this inspection report can be made available in other formats on request. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The comprehensive assessment process ensures peoples diverse needs are met on an individual and continual basis. EVIDENCE: People have lived at the home for a long time and there have been no new admissions. Current case files contain detailed assessments, which were made at the time of admission and the organisation have a detailed admissions procedure, which requires a comprehensive multi-disciplinary assessment. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plans are comprehensive, detailed and give specific information about service users as individuals and include good risk management plans. This makes sure that they can make decisions about how they live their lives. EVIDENCE: There are individual support plans in place for all the people who live in the home. People have an allocated key worker and co-key worker who works with them, their families and representatives. The plans are well structured, clearly show individual choices and are outcome based. There was evidence of ongoing assessments covering all aspects of personal and social support and healthcare needs. Care plans are reviewed regularly Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 10 with the person’s involvement, where this is appropriate and where they are able. Key workers evaluate the care plans regularly, with an informal review held six monthly or as necessary and major reviews are held annually with other professionals. A comprehensive number of risk assessments and risk taking documents are maintained and are clearly linked to care plans. There was evidence of risk taking strategies in place for each person with regard to all aspects of personal daily living activities. Individuals are enabled to take as much control over their lives as possible. Any restrictions in place to make sure a person is safe or other people remain safe are clearly recorded in partnership with other professionals and representatives. Any unexplained absences are promptly responded to by informing police, CSCI and other professionals. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are well integrated within the local community leisure facilities to ensure they are involved in appropriate facilities of their choice. The meals are balanced and nutritional and cater for the varied dietary needs of service users. EVIDENCE: Staff aim to make sure that each person can have an ordinary life and they also aim to make sure they have choices about how goals can be reached within a risk assessment framework. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 12 People are fully supported by the staff to maintain family links and friendships. Relatives are encouraged to visit the home and staff actively encourage family contact by personal visits or by assisting individuals to send cards to families and friends. Where possible staff will offer advice and support to develop or maintain personal relationships outside the home. People have varying level of autism which can restrict interactions and relationships between others, however the staff have an in-depth knowledge of the individual needs and behaviours and have been able to develop and maintain positive interactions between some of the people who live in the home. Staff make sure that everyone is given the opportunity to access activities at the Croft centre or in the local community. Some people prefer one to one outings and activities; others can take part in-group events. Activities outside of the home include, horse riding, swimming, walking, and visits to local pubs and cafes. The home also has its own transport which helps people get out on an individual and group basis. There are two dining areas and everyone eats together where possible. Should anyone need to have their meals alone this is respected and carefully managed. The people living in the home are unable to assist with food or drink preparation and there are restrictions to the kitchen area for their safety. They are consulted about the meals and the staff have an in depth knowledge of individual likes and dislikes. Staff also support people to follow a healthy and balanced diet. At mealtimes two choices of meal are offered so that everyone can choose exactly which they prefer. Choices are also offered for dessert and drinks are readily available. The lunchtime meal was flexible and a relaxed time. Staff were patient and gave support and assistance in a sensitive manner. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plans are comprehensive and person centred, this ensures people’s needs are recognised and fully met. People’s health and personal care needs are well met. Any risks are well managed to help people lead the life they want. Robust systems for the administration of medicines are in place and ensure that people using the service receive their medicines safely. A good level of personal support promotes peoples right to privacy and dignity. EVIDENCE: All of the people living in the home have very detailed care plans in place. Care plans focus on a person centred approach to care and they show that staff make sure that both personal and health care is given in a consistent manner. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 14 No one can manage his or her own healthcare. Staff are extremely well trained and alert to any changes in mood, behaviours and general well being of each person. Care plans give details of the person’s health conditions, any medication they are currently receiving and any other treatments the person is receiving. Clear information is available about chiropody, dentist, opticians and specialist consultants involved with the persons care. Records show that people receive annual health checks. The staff confirmed that all records are regularly evaluated and any actions required are documented. Staff make sure that personal care is given in a sensitive and discreet manner. There are comprehensive medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of the Medicine Administration Records (M.A.R.) showed no discrepancies. There is a register of staff who are authorised to administer medication. Audits are carried by staff to check that quantities are correct and each medicine given out is countersigned. No one currently self-medicates. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The complaints procedures are clear and easily accessed. This helps people to feel confident that their views are listened to and acted upon. Robust arrangements for Safeguarding Adults help to protect people from harm. EVIDENCE: The complaints procedure is very clearly written and is in a pictorial format. It includes timescales and references to an advocate. A copy is in every persons plan, the service user guide and is shared with relatives. Where possible peoples views about life in the home is sought so that improvements to the service can be made. One complaint has been dealt with at Company level. Safeguarding Adults policies and procedures are available to all staff. They give clear guidance about any action to be taken should there be any suggestion or allegation of abuse. All staff working in the home are fully trained and know how to respond to an alert. Staff training is constantly updated in regard to restraint, physical and verbal aggression. There have been no safeguarding adult referrals since the last inspection. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment is variable and does not always provide people with an attractive and comfortable place to live. EVIDENCE: The home is a large Victorian villa with spacious furnished shared areas. There are two lounges, which have dining areas and two individual lounges for designated people. There are seven single bedrooms and also a semiindependent living flat, which is on the top floor. The people who live in the home are very mobile and need little in the way of aids and adaptations. Communal areas get a lot of wear and there is damage to walls and armchairs. One lounge carpet is torn and the damaged area is covered with a small mat. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 17 The bedrooms meet individual needs. Some have small items that reflect peoples likes and preferences others have minimal decoration and personal items. On the day of inspection the home was clean, tidy and had no odours. The laundry is separate and is domestic in style. It was generally organised and free from infection. Staff have received training in infection control. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The current staffing levels and staff deployment ensures peoples assessed needs are met. Clear arrangements for training and robust recruitment ensure that people are protected and staff are competent. EVIDENCE: Although there have been some recent recruitment problems the staff make sure that there are plentiful staff at all times to make sure the diverse and complex needs of individuals’ are always met. The staff said there was “always lots of training and support to do the job well”. Staff have completed induction and statutory training. This includes first aid, fire training, food hygiene, moving and handling and record keeping. Where Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 19 necessary training is provided on an individual basis to make sure the staff can consistently meet people’s needs. All staff receive specialist training to make sure they understand and are up to date with the needs of people with autism specific disorders. The Learning Disabilities Awards Foundation (LDAF) externally accredits courses. Over 85 of staff have achieved an NVQ level 2 qualification. There was evidence that regular staff meetings take place with minutes kept. Staff are clear about what they wanted to achieve, know what their roles are and work hard to meet peoples needs. Records for recruitment show evidence of Criminal Record Bureau checks, Safeguarding Adult checks, two written references, proof of identity, and completed induction programmes. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although there is no registered manager the senior staff continue to ensure the service is run in the best interests of the people living in the home. Staff receive the support and direction they need to carry out their jobs. The staff demonstrate a good understanding of their roles and responsibilities. The systems for quality monitoring are satisfactory. The home endeavours to maintain the health, safety and welfare of residents, staff and visitors as far as reasonably practicable. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager has transferred to another service within the Company. The home is currently without a designated manager and senior staff are taking on this role. The person in charge on the day of inspection was very knowledgeable about all aspects of the service provision. All of the staff are working hard to continually improve the service and provide a high quality of life for the people who live there. The staff said they were able to discuss any issue that they had and felt they had a good team. They were all looking forward to having a permanent manager for the service. There was a good atmosphere in the home and all of the staff interacted with each other openly and with respect. The home has quality assurance systems in place. Monthly visits from the line manager take place with records kept. Regular in house audits include care plans, medication, health and safety and maintenance issues. Policies and procedures are regularly reviewed and updated according to the Company’s policy. Staff have received training in safe working practices including fire, first aid, moving and handling, food hygiene and infection control. Risk assessments and health and safety checks are carried out with dates and signatures recorded. Accident records were clear, up to date and kept in line with the Data Protection Act. Accidents and incidents are reported to the Commission when required. Since the recent visit from the Fire Officer the staff have started to make sure weekly fire checks are completed with records kept. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 2 X 3 X X 3 X Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 23 NO 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 YA24 Regulation 13,23 Requirement The registered person must ensure that the damaged and worn lounge chairs are replaced. The registered person must ensure that the lounge carpet is replaced. The registered person must recruit a suitably qualified manager. Timescale for action 01/07/07 2 3 YA24 YA37 13,23 8 30/06/07 01/08/07 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 YA24 Good Practice Recommendations The registered persons should continue to redecorate and refurbish the home. Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holly House DS0000056857.V334438.R02.S.doc Version 5.2 Page 25 - 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. 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