Inspection on 06/06/07 for Holly House

This inspection was carried out on 6th June 2007.

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 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 17/11/05

Holly House 13/06/05

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 Bronwynn Bennett Key Unannounced Inspection 6th June 2007 09:00 Holly House DS0000003116.V315168.R01.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 DS0000003116.V315168.R01.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 DS0000003116.V315168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly House Address Greasbrough Road Parkgate Rotherham South Yorkshire S62 6HG 01709 523241 NONE NONE 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) Patricia Burgin Patricia Burgin Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All existing service users may remain at the home after they reach the age of 65 years. 17th November 2005 Date of last inspection Brief Description of the Service: Holly House is a home that accommodates 12 people with learning disabilities in the category of younger adults, with some people 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 semi-independent 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 DS0000003116.V315168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit. The inspector arrived at the home at 9.00am and left at 3.30pm. During this visit the inspector spoke with people living at Holly House, some of the staff and the manager Mrs Patricia Burgin. The inspector looked at records of people’s care, staff records, how medicines are given and carried out a tour of the home. In addition to this visit the Commission for Social Care Inspection sent questionnaires to people who live at Holly House. Six questionnaires were returned. The inspector did observe the care people receive and how the staff treat people. There were twelve people living at the home on the day of this visit. Surveys were sent to five relatives and five healthcare professionals. Comments from five relatives were received. Before we visited Holly House the manager gave the CSCI information about illnesses, accidents and incidents and how the home is managed The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The service offers a warm and friendly home where people feel comfortable, relaxed and able to express themselves. People’s individual and potential needs are assessed prior to admission into the care home. People who live at Holly House enjoy good working relationships with the staff. During this visit people spoken with said they were happy with the staff working at the home. The staff team work well to enable people to be part of the local community and take part in community activity. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 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 DS0000003116.V315168.R01.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 DS0000003116.V315168.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are looking to moving into the care home have their needs and aspirations assessed. EVIDENCE: The process for admitting people to the home was discussed with the manager. There was a comprehensive assessment in place in the records examined, that demonstrates the home is able to meet the needs of the individual prior to their admission. Four people that took part in the CSCI survey said that they did receive enough information about the home before they decided if it was the right place for them. Holly House DS0000003116.V315168.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally individuals personal needs and goals are recorded. As is the support required by the person to make decisions and take risks as part of an independent lifestyle. EVIDENCE: Twelve people were living at Holly House on the day of this visit. The home provides people with a homely and relaxed atmosphere where people are supported to make choices and decisions in their lives. And staff were seen interacting well with individuals living at the home. Three people said they are “always” able to make decisions and three people said they “usually” make decisions about what they do each day. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 10 The care records for two people were looked at. Both records held good information relating to the individuals strengths and needs. Generally, the care records were detailed; person centred and reflected the individuals’ preferred choices and lifestyle. There were risk assessments in place to minimise individual risks and hazards that enable people to enjoy an independent lifestyle. The daily records showed good detailed information that related to the person’s care plan and how the individual had spent their day. However, greater care is required to ensure that all the required information is carried forward when care records are reviewed and updated. This ensures the staff have up to date information relating to each individual. The manager said that people are involved in the information that is recorded in their care plan, but this was not evidenced in the care records looked at. The manager agreed to address this matter. Holly House DS0000003116.V315168.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to be part of the local community and take part in appropriate activities. Individuals are supported to maintain relationships with family and friends. Generally, the rights of people are respected with their choice and independence being promoted. EVIDENCE: The people spoken to during this visit said they are able to choose what they do each day. Everyone that responded to the questionnaire said they can do want they want to do during the day, at weekends, and in the evening. People are encouraged and supported to be part of the local community. Some individuals are in paid work and there are opportunities for people to go out to local clubs and groups. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 12 The people spoken to during this visit said that they plan trips during resident meetings and enjoy things such as, bingo, walking groups, shopping and barbecues. Individuals also receive the support to develop their own interests and hobbies. The staff were observed treating individuals in a respectful and dignified manner throughout this visit. The individuals right to spend some time alone was also respected by the staff. Individual relationships with family and friends is encouraged and supported. There are no restrictions on visiting the home and people are supported to spend time with family and friends. People are supported with dietary needs and specialist diets such as diabetic meals. Everyone takes part in planning menus and assist with the shopping and preparation of meals. Individuals spoken to during this visit said they liked the food at the home. Holly House DS0000003116.V315168.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support in the preferred way and generally their health care needs are being met. The medication policy and procedure sufficiently protect people living at the home. EVIDENCE: During this visit people were seen interacting well with the staff at the home. As part of the survey people were asked, do the staff treat you well and do carers listen and act on what people say. Three people responded “always” and three people said “usually”. People spoken with during this visit said that they are supported in their chosen way. And they can choose times for rising and going to bed, bathing, and other activities. Individual personal preferences were seen recorded in the care records looked at. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 14 The care records looked at showed that people are supported to access NHS healthcare facilities such as a doctor and other professionals. Everyone living at the home is currently being given a healthcare action plan. This is written in a way for everyone to understand and will include all the information for each individuals healthcare. The medication and the medication records looked at were of a satisfactory standard. Holly House DS0000003116.V315168.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home, their relatives and advocates are confident their views are listened to and acted upon. People are protected from abuse. EVIDENCE: There have been no complaints made to the home since the last visit by the CSCI. The home has a complaints policy displayed. However, this is in need of updating to include the required timescales for responding to any complaints made to the home. This was discussed with the manager who agreed to take action in this matter. The complaints procedure is not in suitable formats for people living at the home. This was discussed during this visit and a recommendation is made in the report about this. Everyone who responded to the survey said they knew who to speak to if they were not happy and knew how to make a complaint. The relative surveys received by the CSCI showed that people are aware of the home’s complaints policy and procedure. The staff have undertaken vulnerable adults training and one of the staff spoken to had a good understanding of the necessary actions that must be taken should there be any allegations of abuse. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 16 The money and the financial records were checked for two people living at the home and were correct. Some people have chosen to handle their own finances and are provided with secure facilities for privacy and safekeeping. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 17 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 use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally clean and hygienic. However, the arrangements in respect of the fire escape need to be clarified with the fire service to ensure people are safe. EVIDENCE: On the day of this visit a tour of the home was carried out and the home was generally fresh and clean. The general areas of the home offer a comfortable environment for people sit and relax. Five people that responded to the survey said the home was “always” fresh and clean. There are major refurbishment works currently being carried out to the coach house area of the home. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 18 The individual rooms looked at showed personal touches have been made by people living at the home. The laundry facilities do not have a separate sink for hand washing. Separate hand washing facilities promote good hygiene standards and prevent the risk of communicable diseases. This was discussed with the deputy manager and a recommendation is made in this report about this. This area is in need of some organisation and removal of clutter stored. The laundry floor requires repainting to ensure it provides a surface that can be cleaned easily. At the rear of the property is an enclosed fire escape that is in need of a thorough clean and some maintenance work. The construction of the canopy covering the fire escape should be checked to ensure it meets the current fire and health and safety requirements. The smoke seals fitted to the interior doors had been painted with gloss paint. It is a concern that once painted; these seals may not function properly (to reduce the smoke going from one room to another) in the event of a fire. These concerns have been raised with the fire safety officer and the owner of the home. It is a requirement of this report that the manager seeks advice and information from the fire service to ensure the home meets fire safety regulations. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 19 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): 32,34 and 35. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall a competent staff team supports people living at the home. Generally, people are protected by the organisations recruitment policy and procedure. EVIDENCE: Three people that responded to the survey stated that the staff “always” treated them well, and three people said the staff “usually” treated them well. All the relative surveys received by the CSCI showed that people were satisfied with the overall care provided at Holly House. One relative commented that Holly House was an excellent home and the staff were kind and caring. There are eight care staff working at the care home, seven staff have achieved the NVQ (National Vocational Qualification) level 2 or above in care. And some staff are undertaking NVQ level 3. The staff receive induction training (the training given to all new staff) that meets the required standards. The staff records looked at showed evidence of ongoing training for the staff. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 20 The employment records for two staff working were looked at. One of the records held the required information to ensure that people are protected by the home’s recruitment practices. However, one record did not contain a completed application for employment. This was discussed with the deputy manager who agreed to take action. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 21 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): 37,39 and 42. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a well run home that is generally run in their best interests. Greater care is required to ensure the health, safety and welfare of everyone is sufficiently promoted and protected. EVIDENCE: The registered manager and owner of the home is Patricia Burgin. She has many years experience of caring for people who live at Holly House. The manager and deputy manager have completed the RMA (Registered Managers Award). Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 22 There is some quality monitoring taking place through staff meetings, resident meetings and individual care reviews, and relative questionnaires. A visiting professional said that they were satisfied with the home, and they found the staff helpful and welcoming. The deputy manager said they are in the process of implementing a quality monitoring tool to monitor the services that are currently being provided. There should be an effective quality monitoring system that seeks the views of people who live at the home, family, friends and relevant professionals. The results should be published and made available in suitable formats for everyone to read. The fire records were looked at and showed that there are weekly checks of the home’s fire alarm system. However, there were no up to date records to show the emergency lighting is tested on a weekly basis. This was discussed with the deputy manager who said a visual daily check is carried out to the emergency lighting. She agreed to take immediate action in this matter and ensure the relevant records are kept. The staff have received fire safety training and there have been fire drills at the home. The fire training is now due to be updated to ensure the staff are aware of the procedures to follow in the event of the fire alarm being raised. The deputy manager said that all the staff have received training in health and safety, food hygiene and first aid. However, the staff have not yet received infection control training (to prevent the spread of infection and communicable diseases) This was discussed with the deputy manager. It is a recommendation in this report that all staff complete infection control training. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 23 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 23.4 Requirement The registered person must seek advice and information from the fire service to ensure the home meets fire safety regulations. The smoke seals to the interior doors and the fire escape must be checked. Timescale for action 04/07/07 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. 2. 3. 4. 5. Refer to Standard YA6 YA22 YA24 YA30 YA30 Good Practice Recommendations Greater care is required to ensure all the required information is available in care records kept for each individual. The home’s complaints procedure is in need of updating to include the required timescales for responding to any complaints made to the home. The fire escape should be cleaned regularly to ensure it is free from dirt and debris. The laundry facilities should be fitted with a suitable hand wash sink to promote good hygiene practices and prevent communicable diseases. The laundry room floor should be repainted to provide DS0000003116.V315168.R01.S.doc Version 5.2 Page 25 Holly House 6. 7. YA34 YA39 8. 9. 10. YA42 YA42 YA42 ensure it can be cleaned easily. All the staff files should have a completed application for employment to ensure the recruitment processes sufficiently protect the people living at Holly House. The home should continue to develop a quality assurance and quality monitoring system to seek the views of people living in the home, their relatives, and any other interested people. The checking of the homes emergency lighting should be recorded on a weekly basis. Fire training should now be planned for all the staff working in the home to ensure they are kept up to date with such training. Infection control training should be completed by all the staff to promote good hygiene practices and prevent communicable diseases. Holly House DS0000003116.V315168.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000003116.V315168.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!