Inspection on 15/09/05 for Holly House

This inspection was carried out on 15th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 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 01/05/07

Holly House 20/02/06

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 Lesley Scriven Unannounced Inspection 15th September 2005 09:30 Holly House DS0000056857.V256723.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 House DS0000056857.V256723.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 House DS0000056857.V256723.R01.S.doc Version 5.0 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 Mr Anthony Reineck Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Holly House DS0000056857.V256723.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2005 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 and nicely 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. Holly House DS0000056857.V256723.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours on one day. Time was spent with six of the people living at the home, although some had limited spoken communication skills and the inspector was very dependent upon the observations she made of the relationships between service users and staff. A lunchtime meal was also taken with a small group. As part of a case-tracking exercise one service user file was read. Some staff training and supervision records and complaints records were also checked, along with the home’s incident and intervention logs and fire logs. A sample audit of the home’s system for receiving, storing, administering and disposing of medication was carried out. A partial tour of the premises and grounds looked at the standard of accommodation and facilities on offer and arrangements for maintaining safe living and working conditions. The manager and nine staff were asked about the running of the home and the support and training they receive to enable them to do their jobs. What the service does well: Service users are as far as possible encouraged to be independent and make choices while enjoying life in and outside of the home. They are supported to take responsible risks but at the same time are protected from harm by staff who take time to get to know each person and their individual strengths and limitations. There are excellent opportunities to become involved in a wide range of social and leisure activities at the home, at ESPA’s Croft Centre and in the wider community. This enables service users to develop relationships with people who have similar interests and to learn new skills. Meals on offer at the home are particularly good and mealtimes are relaxed and sociable and take place in pleasant surroundings. The home is always well staffed and the support team is properly trained and well supervised so that a good standard of care can be delivered. This is confirmed by a visiting family member who reports “100 confidence in the staff at all levels” and says that he has never had any cause to complain. Holly House DS0000056857.V256723.R01.S.doc Version 5.0 Page 6 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 House DS0000056857.V256723.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 House DS0000056857.V256723.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): None of these standards was inspected at this visit. EVIDENCE: Holly House DS0000056857.V256723.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): 7 and 9 Wherever possible people are encouraged to make choices, take control over their lives and be as independent as possible, but this can sometimes be limited in an agreed way to reduce the risk of emotional or physical harm EVIDENCE: Service users are encouraged to take as much control as possible over their own lives and be independent in areas such as personal care. People are also supported to take responsible risks: in relation to making drinks and snacks independently for example, or taking part in outdoor activities. In these cases, the manager always carefully assesses the hazards and level of risk involved and weighs up the benefits and pitfalls. Clear guidelines are then put in place so that staff can give people the correct level of assistance to reduce as far as possible the likelihood of anything going wrong. Sometimes however, choices or freedom of access inside the home and especially outside might be restricted to ensure a person’s safety, or the safety of others around them. Where limitations are necessary, they will only be put in place after consultation with the service user and their supporter and other professionals who specialise in autism specific disorders. All decisions are well documented and regularly reviewed. Holly House DS0000056857.V256723.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): 11, 12, 14 and 17 People who live at Holly House are supported to take part in a wide range of social, leisure and learning opportunities not just within the home, but at the Croft Centre and in the local and wider community too. This is important for their personal development. Meals on offer at the home are thoughtfully prepared, nutritious and nicely presented. Mealtimes are structured to suit the needs of service users and people eat in homely surroundings. EVIDENCE: People living at Holly House are offered excellent opportunities to take part either individually or with their friends and supporters in a wide range of social, leisure and learning activities both at the home and in the community. This enables them to develop and maintain relationships with people who have similar interests and to learn new skills. People attend ESPA’s Croft Centre on a regular basis and one person is involved in the ‘well women’s group’ there. Activities outside the home include swimming, outward-bound ventures, horse riding and visiting local pubs and cafes, whilst indoors people can enjoy aromatherapy, sessions in the sensory room and arts and crafts. A number of Holly House DS0000056857.V256723.R01.S.doc Version 5.0 Page 11 holidays are also taken each year to destinations of user’s choice and at the time of inspection three people were staying with staff at a cottage in Dalbeattie. Service users and staff eat together in two rooms and users are grouped according to how well they get on. Meal times are relaxed and sociable and where support is needed, this is respectfully and discreetly offered so that noone’s dignity is undermined. Meals are varied, tasty and nicely presented and people’s special dietary needs are met. Two choices are offered at every sitting. Nutritional screening and regular weight monitoring are included in the support-planning process so that healthy living styles can be adopted. Holly House DS0000056857.V256723.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 Very good systems are in place to enable staff to safely assist people with medication. At the present time, no one living at the home is able to keep or administer their own medication independently, but suitable procedures are in place if needed. EVIDENCE: Properly trained staff follow sound policy and procedural guidance to make sure service users are safely assisted with medications. Medicines are carefully ordered, securely stored and appropriately administered and accurate records are kept. Holly House DS0000056857.V256723.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): 22 and 23 The views of service users and their supporters are taken seriously and appropriate action is taken to resolve concerns and complaints. The home works to satisfactory policy and procedure to ensure that people living there are protected from all types of abuse and as far as possible from self-harm. EVIDENCE: The home has a clear and easy to understand complaints procedure which service users are able to access. People’s views about life at the home are regularly sought so that the service can be improved and user’s and supporter’s concerns and complaints are properly looked into and resolved. ESPA has a very good policy for ensuring the protection of vulnerable adults. Staff have received training to help them put this into practice and know what to do if any concerns about service user’s well-being or safety come to light. On occasion they may need to use physical intervention in order to prevent people from hurting themselves or others, but only safe techniques are used by staff who have been properly trained. Detailed records are kept to enable a better understanding of the circumstances that trigger user’s challenging behaviours so that support strategies can be put in place to prevent further occurrences. Holly House DS0000056857.V256723.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): 24 and 30 People who live at the home benefit from an environment which is well maintained, safe, clean and comfortable. EVIDENCE: Holly House has a homely feel and is nicely decorated with good quality furniture that suits the age and lifestyle choices of the people who live there. Bedrooms either reflect user’s interests and personalities, or are decorated in a very minimal way according to individual needs. The additional detached house within the same grounds is still undergoing modernisation and redecoration and provides useful additional indoor space for leisure activities. Staff keep both properties clean and tidy and free from infection to the benefit of everyone’s health. The grounds are well maintained and provide pleasant additional space in the summer months. Where appropriate, environmental adaptations have been fitted and equipment is used to maximise people’s independence. These are regularly checked to ensure they remain fit for purpose. Holly House DS0000056857.V256723.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, 33, 35 and 36 The team at Holly House is sufficient in number, with the right mix of skills and experience to meet the assessed needs of the people who live there. Regular appraisal, training, supervision and support is provided for each member of staff to enable them to carry out their jobs to a good standard EVIDENCE: The home’s manager ensures that there are always sufficient staff on duty so that service users are fully supported to meet the goals and aspirations of their individual lifestyle-plans. One-to-one support is always available for those who require it and this does not reduce the quality of service received by others living at the home. Team members are provided with regular training opportunities to equip them to better understand the needs of people with autism specific disorders. Courses are accredited by the British Institute for Learning Disabilities (BILD) and the Learning Disabilities Awards Foundation (LDAF). Good progress is being made with National Vocational Qualification (NVQ) training and all workers are encouraged to develop their skills through reflective practice at supervision. In doing this they are able to learn from past experience. With the support of the manager and ESPA’s specialist advisors they use current best practice guidance to adopt different enabling approaches to suit the very different needs of service users. Holly House DS0000056857.V256723.R01.S.doc Version 5.0 Page 16 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): 37, 38 and 42 The manager works closely and effectively with the staff team to ensure the home is well run and a safe and pleasant place to live. He is working towards the necessary management qualifications to meet the requirements of national minimum standard. EVIDENCE: The home’s manager has worked with ESPA for many years now, supporting adults who have special needs, and is suitably experienced to work at a senior level. He has management qualifications and special educational needs teaching certificate. He is also studying towards a National Vocational Qualification (NVQ) level IV award in ‘care’ and is a trained NVQ assessor. He puts a lot of effort into keeping up to date with current best practice guidance and sharing his knowledge with the team. As a result service users are offered a very good standard of support in a safe environment. It is clear that Mr Reineck has developed warm and trusting relationships with the people who live and work at Holly House and this makes the home a pleasant and friendly place. Holly House DS0000056857.V256723.R01.S.doc Version 5.0 Page 17 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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 3 12 4 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly House Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 x x x 3 x DS0000056857.V256723.R01.S.doc Version 5.0 Page 18 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 YA37 Regulation 9 ((2) (b)(1)) Requirement The registered manager must complete the NVQ Level IV award in ‘care’. Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. N/A Refer to Standard N/A Good Practice Recommendations N/A Holly House DS0000056857.V256723.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 DS0000056857.V256723.R01.S.doc Version 5.0 Page 20 - 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. 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