Inspection on 20/02/06 for Holly House

This inspection was carried out on 20th February 2006.

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 4 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 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 Gillian McCabe Unannounced Inspection 28th February 2006 10:00 Holly House DS0000056857.V276683.R01.S.doc Version 5.1 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.V276683.R01.S.doc Version 5.1 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.V276683.R01.S.doc Version 5.1 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.V276683.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 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 semiindependent 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-leSpring, 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.V276683.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one full day on February 28th 2006. The inspection was unannounced therefore the views of service users, relatives and other visitors to the home were not gathered prior to the inspection. Service users satisfaction of the service provided at Holly House was found by observation. The assistant manager and some of the support workers views were also given about the running of the home and the support and training they receive to help them to do their jobs. A sample of records was inspected. Two service users files were looked at along with one member of staffs file. Quality assurance records were looked at, training records, maintenance plans and records of meals. A tour of the premises looked at the standard of accommodation and facilities on offer, and arrangements in place for maintaining a safe living and working environment. What the service does well: What has improved since the last inspection? What they could do better: Service user files containing old records could be reviewed and organised more effectively to ensure all information is accessible. Risk assessments could be written more descriptively to inform the reader exactly how to give the right kind of support. Holly House DS0000056857.V276683.R01.S.doc Version 5.1 Page 6 Service user contracts could be completed with the date and signature of the person whose contract it is. 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.V276683.R01.S.doc Version 5.1 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.V276683.R01.S.doc Version 5.1 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): Standard 2 is the key standard to be inspected however it was not was not assessed because no new service users have been admitted to the home since the last inspection and the home continues to have comprehensive and up-to-date assessments in place for each person. EVIDENCE: Holly House DS0000056857.V276683.R01.S.doc Version 5.1 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): 6 Service Users assessed needs are clearly set out in individual plans of care, this enables staff to deliver the correct amount of support for each person. Service users are supported to take risks as part of an independent lifestyle, staff follow guidelines to ensure the correct level of support is given to minimise any potential risk EVIDENCE: Holly House has very detailed support plans in place for all service users detailing the persons needs, wishes and aspirations. The plans cover areas such as communication needs, plans for the future including long and shortterm goals. Plans are in place detailing vocational activities and what the person wants to do in the future. Some of the plans were not dated. The assistant manager confirmed that support plans are evaluated on a six monthly basis however documentary evidence of evaluations was not clear in individual files. The home has very detailed risk assessments in place for all service users. As all plans encourage promoting independence, this can involve a degree of risk i.e. Some people might like to carry out particular activities that may pose a Holly House DS0000056857.V276683.R01.S.doc Version 5.1 Page 10 risk. Where this is the case, the manager and staff carefully assess the level of risk involved and plan how to minimise such risks. Guidelines are also in place for staff to support people to minimise any potential risks there may be. Risk assessments give clear details of the type of support a person may need to carry out the potential risk as independently and as safely as possible. Some of the language used in risk assessments could be more descriptive, for example, ‘appropriate levels of support’ is used. This type of language is not specific enough to ensure the person receives the right kind of support to carry out the task. Overall, support plans and risk assessments are detailed and give instruction to ensure support is given correctly. Holly House DS0000056857.V276683.R01.S.doc Version 5.1 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 the following standard(s): 13,15 & 16 Service Users are assisted to lead fulfilling and active lifestyles by accessing a wide range of community facilities and having regular community presence. People who live at Holly House are encouraged and supported to maintain contact with friends and family inside and outside the home. Service users rights and responsibilities are respected and recognised by staff at Holly House. EVIDENCE: Service users are promoted to follow their own lifestyles and maintain contacts with family members and friends. Friends and family members are always welcomed and encouraged to visit the home at any time. Service users can choose where to see their visitors, for example, in the main lounge or in the privacy of their own room. Service users are supported to access facilities in the community. Some service users are offered the opportunity to access excellent facilities at ESPA’s (European Service for People with Autism)‘Croft centre’. There are various groups that meet at the Croft centre and lots of activities, things like meal Holly House DS0000056857.V276683.R01.S.doc Version 5.1 Page 12 preparation and cooking, well women’s groups, service user consultation steering groups, arts and crafts, pottery clubs, archery and information technology. The assistant manager is responsible for planning and organising in house trips with service user involvement. The assistant manager plans and discusses the type of things people like to take part in. Some people prefer one to one trips while others like group activities. Activities such as bowling, visits to the cinema, walking and trips out to the countryside. The home also has the benefit of its own accessible transport, which helps to get people out and about. The assistant manager also talked about holidays that are planned for service users in the future. Some people like to places like the Calvert Trust in Keswick, Barnard Castle and one service user has previously enjoyed a trip to Norway. The daily routines carried out in the home promote independence and individual choice; any restrictions imposed are documented in a persons support plan. Members of staff enter service users room only with permission and always knock on the door before entering. Holly House DS0000056857.V276683.R01.S.doc Version 5.1 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 the following standard(s): 19 The manager and staff ensure that service users physical and emotional health needs are met, which promotes a good healthy quality of life for service users. EVIDENCE: The home has very detailed health profiles in place for all service users. Care plans give a lot of detail to allow any new member of staff to provide the correct level of support for each person living at Holly House. The profiles give details of the person’s health conditions, any medication they are currently receiving and any other treatments the person is receiving. The profiles cover areas such as chiropody treatment, dentist visits, and optician visits, specialist consultants involved with the persons care. All service users health needs are well monitored and any concerns are dealt with immediately by referral to the appropriate professional. Records show that service users receive annual health checks. The manager and staff confirmed that all records are evaluated on a monthly basis and any actions required are documented. The way information is stored would benefit from being reviewed as a lot of old information, which may not be relevant to the person, is currently stored in service users files. Holly House DS0000056857.V276683.R01.S.doc Version 5.1 Page 14 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): All key standards assessed and met at previous inspection. EVIDENCE: Holly House DS0000056857.V276683.R01.S.doc Version 5.1 Page 15 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): All key standards assessed and met at previous inspection. EVIDENCE: Holly House DS0000056857.V276683.R01.S.doc Version 5.1 Page 16 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): 34 The company has a thorough recruitment policy in place based on equal opportunities and ensuring the protection of service users. EVIDENCE: The home has a detailed policy and procedure in place that is followed when recruiting new staff. Records show all relevant documents are in place for members of staff, for example, references, criminal record bureau checks and application forms. The assistant manager confirmed that service users where possible are supported to be involved in staff recruitment and selection process. Holly House DS0000056857.V276683.R01.S.doc Version 5.1 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 Holly House has effective quality assurance systems in place to ensure the views of service users take place. EVIDENCE: The home has a service user consultation policy in place. The company’s Croft centre has regular service user consultations to discuss, share information and gain feedback about the service it provides and any other issues that may be relevant to service users. A steering group meets on a regular basis and minutes of meetings held are forwarded to the home and members of staff feedback details of minutes recorded to service users. All service users have the opportunity to be a part of the steering group. The home uses questionnaires to seek feedback regarding the services provides. Questionnaires are issued to service users, relatives and friends and information is used to measure success. No records or samples of questionnaires were available to be seen. Holly House DS0000056857.V276683.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X X X 3 X X X X Holly House DS0000056857.V276683.R01.S.doc Version 5.1 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 YA5 Regulation 17(1)(a) Sch 3 15(2)(a) 15(2)(a) Requirement Service user contract/terms and conditions must be signed by service user or advocate and company representative. Support Plans evaluations must include the date. Risk assessments must be sufficiently detailed to show staff exactly how to support people correctly. Freestanding wardrobes must be fitted with an anti topple device. Timescale for action 30/04/06 2. 3. YA6 YA6 30/06/06 30/05/06 4. YA42 13(4)(a) 01/03/06 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 must complete the NVQ Level IV award in ‘Care’. Holly House DS0000056857.V276683.R01.S.doc Version 5.1 Page 20 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.V276683.R01.S.doc Version 5.1 Page 21 - 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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