Inspection on 13/06/05 for Holly House

This inspection was carried out on 13th June 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly House 06/06/07

Holly House 17/11/05

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 09/07/2008.

CARE HOME ADULTS 18-65 Holly House Greasbrough Road Parkgate, Rotherham South Yorkshire S62 6HG Lead Inspector Valerie Hoyle Unannounced 13 June 2005 11:00. th 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 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 Stationary 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 CS0000003116.V180041.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holly House Address Greasbrough Road, Parkgate, Rotherham, South Yorkshire, S62 6HG 01709 523241 NONE NONE Mrs Patricia Burgin Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Patricia Burgin Care Home 12 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (3) of places Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named service users over the age of 65 be allowed to reside at the home. This condition will cease to apply when they leave the home. Date of last inspection 10-Jan-2005 Brief Description of the Service: Holly House is a home that accommodates 12 service users with learning disabilities in the category of younger adults, with three service users 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 semiindependent 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. Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over 5 hours where a partial tour of the building was undertaken. The inspector examined five service users care plans and supporting documentation. Two staff was spoken to during the visit. Staff was observed interacting with service users in a positive supportive manner, enabling them to participate in daily living skills. The deputy manager assisted with the process while examining records, policies and procedures. What the service does well: What has improved since the last inspection? Decoration and furnishings are being gradually improved and those areas are looking more welcoming and homely. New floor coverings in bathrooms and a new bay window in the main lounge has improved these areas, and it is hoped that the second large window will be replaced shortly. Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 6 Care plans have been improved and now reflect the current needs of service users. The registered manager will now need to examine the assessment document to use when admitting new service users. 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 House CS0000003116.V180041.R01.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Holly House CS0000003116.V180041.R01.doc Version 1.30 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 standard(s) 2, 4. Service users are not admitted into the home without a full needs assessment taking place by the registered manager, to ensure their needs can be met. Procedures ensure that visits take place prior to any arranged stays at the home. EVIDENCE: Examination of the homes admissions policy demonstrated the procedures that would be followed for any new admissions to the home. Service users have lived at the home for a number of years; five service users files examined demonstrated that comprehensive assessments have taken place to ensure staff are able to meet care needs, although some have not changed for a considerable length of time. Discussion with staff on duty and service users demonstrates that prospective service user are given the opportunity to visit the home on a number of occasions prior to making any decision about their stay. Service users said that a new person had visited for tea and they all got on with him/her. They said they thought he/she would fit in with them. Holly House CS0000003116.V180041.R01.doc Version 1.30 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 standard(s) 6, 7, 9. The home clearly promotes philosophies to enable service users to meet their full potential, with clear care plan instructions and comprehensive risk assessments to maximise their safety and protection. EVIDENCE: Five care plans were examined they contained sufficient information to enable staff to deliver the required care to service users. Care plans described information relating to health, personal hygiene, activities, relationships, behaviour and communication. One service user said she/he knew what was written about him/her in their care plan and was happy with the care at her/his home. Care plans are reviewed monthly by the keyworker and annual reviews take place to include family members and staff from the training centres. Risk management strategies had been identified and recorded in the individual plan. Action was taken to minimise identified risks. The plans evidenced that individual activities and choices were respected and supported within a risk management framework. The registered manager supports service users with their personal monies, as Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 10 they find this aspect of daily life difficult to manage. Clear documentation is used to demonstrate how money is spent and an audit of two service users money was undertaken and was found to be correct. One service user said that she/he keeps her/his wage that she/he earns for her/his job at ‘Speak Up’. Holly House CS0000003116.V180041.R01.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 17. Where appropriate service users are encouraged and supported develop independent living skills. Social and leisure activities are provided at the home for service users, to maintain and develop independent living skills, supported by an informed staff group. Service users are helped to maintain links with family members, with weekend and evening visits, as agreed in their care plans. Dietary needs of service user are well catered for with a varied selection of food available that meets service users tastes and choices. EVIDENCE: Service users are encouraged and supported to maintain links with the local community and a number attend local groups including ‘Speak Up’ and local cinema and dancing groups. A number of service users continue to attend local training centres during the week, and described the activities they take part in during the day. Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 12 Staff described in detail the social activity programmes and service users said that they enjoy trips to garden centres and had visited Ingermells to the market recently. A service user celebrating her/his birthday said they were all going on an outing at the weekend as part of her/his celebration. She/he was happy to show her/his presents and described who had sent her/him them. One service user said she/he enjoyed visits to her/his fathers and has her/his own bedroom their, she/he is thinking of taking some of her/his belongings to personalise the room. Service users are encouraged and supported to undertake routine tasks around the home including laying the tables for meals and putting their own laundry away. One service user said she/he had been doing some ironing and tidying her/his bedroom. Mealtimes are organised around the routines of the service users and the main meal is provided at teatime when it is expected that all service users will be at home. Packed lunches are provided for those service users who are out for the day and some service users are encouraged and supported to make their own lunch in one of the training kitchens. Holly House CS0000003116.V180041.R01.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20, 21. Staff provides sensitive personal support to ensure privacy dignity and independence is maintained for all service users. Medication policies and procedures are well managed and staff have the necessary skills to administer the medication to service users, ensuring the safety and protection of service users. Staff at the home deals sensitively about ageing illness and death to minimise the effects on service users. EVIDENCE: Service users are encouraged to shop for their own clothes and staff assists with this when required. Service users described recent shopping trips to buy new clothing. There were many examples of good practice by staff and on many occasions there were good interactions between staff and service users. Service users were referred to by their first name and this was with the approval of service users, and was also stated in their care plan. An audit of medication stocks and records was examined and were found to be correct. All staff has received accredited medication training provided by a local college, to ensure they have the necessary skills and knowledge to undertake this task Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 14 The registered manager deals sensitively with ageing, illness and the death. All service users have resided at the home for a number of years, and developed friendships towards other service users. Two recent deaths have impacted on the home considerably and service users spoke with some fondness about the friends they had lost while others chose not to speak about their loss, and staff supported these service users. Holly House CS0000003116.V180041.R01.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23. Service users are provided with information to enable them to raise concerns about the home and their care. Adult Abuse Policies and procedures and training of staff on abuse ensure the protection of service users from abuse EVIDENCE: The home has a complaints procedure that is available to service users and visitors that is kept in the entrance. The procedure is also referred to in the service users guide, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure. The registered manager has a copy of the Local Authorities Adult Protection procedures. They also have an Abuse Policy, which has been prepared by the owners and is incorporated into the homes policy and procedure manual. The registered manager reiterates the procedures at staff meetings and supervision and staff training files also confirms that they have attended training in adult protection. The registered manager ensures that all the necessary checks are carried out on new staff for the protection of vulnerable adults. Holly House CS0000003116.V180041.R01.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30. The registered provider continues to improve the décor and furnishings at the home creating comfortable and safe environments for service users. Some further replacement of furnishings and decoration is still needed, although this does not pose a risk to service users. The home is clean and free from odours and there is sufficient domestic staff to maintain good hygiene standards. EVIDENCE: A partial tour of the building found it clean and free from odours. The home provides comfortable communal areas both at the main house and in the smaller unit known as the coach house, where currently the small kitchen is being refurbished with new units, so all service users are having their meals in the main house. The registered providers have replaced the large bay window in the main lounge, which with help with the heating of this area. The grounds were tidy, and accessible to the residents, and the home is close to all local amenities. Individual bedrooms are personalised to resident’s own interests and hobbies and are furnished appropriately to maintain their safety and protection. Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35, 36. Staff have the necessary skills and knowledge to meet the needs of service users. There is an effective staff team with regular meetings and supervision ensures staff are kept informed about the services provided. Recruitment policies are followed ensuring the safety and protection of service users. Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 18 EVIDENCE: Staff are organised to ensure there are sufficient to meet the needs of service users who spend their time at the home during the day. Staffing is increased when most of the service users are at home at weekends and in the evenings. Staff have the necessary skills and have achieved awards in care. Staff have worked at the home for a good length of time and have good relationships with the service users. Service users said that the staff were very supportive and assisted them with tasks they found difficult. A number of staff recruitment files were examined, and there is evidence that all the required employment checks have been undertaken prior to commencing work at the home, ensuring the safety and protection of service users Staff receives supervision and the manager is to undertake all yearly appraisals, to ensure staff have to opportunity to discuss their development. Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42. The home is well managed to ensure the safety and protection of the service users. Staff and service users follow health and safety procedures and records provide evidence of servicing of essential equipment. The views of service users are not formally gained, although this is not detrimental to the service users EVIDENCE: The registered manager, who is also the owner of the home, have considerable experience and knowledge of the service users who have lived at Holly House for a considerable length of time. The manager is working towards achieving the registered managers award and has attended training organised for the staff team. Three separate meeting are to be established giving opportunities for service users the opportunities to play an active part in how the home is run. Formal quality surveys have not been used to gain the views of service users, and this Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 20 was discussed with the deputy manager. This remains outstanding from the previous inspection. Maintenance and service records examined were up to date and current to the services provided. Accident records were fully completed for both service users and staff and the manager carries out her own investigation. The manager has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures are in place and service records were examined and were current. Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 21 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 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 3 x CS0000003116.V180041.R01.doc Version 1.30 Page 22 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 YA39 Regulation 24 Requirement The registered manager must ensure monitoring systems are implemented to formally seek the views of service users.(previous timscale of 1 March 2005 not met). Timescale for action 1 Nóvember 2005 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 manager must achieve the required NVQ Level 4 qualification in management and care in 2005 Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 23 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster DN4 5HZ 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. Extracts may not be used or reproduced without the express permission of CSCI Holly House CS0000003116.V180041.R01.doc Version 1.30 Page 24 - 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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