Inspection on 01/11/05 for Holly House (Barberry)

This inspection was carried out on 1st November 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly House (Barberry) 28/06/07

Holly House (Barberry) 18/01/06

Holly House (Barberry) 27/10/04

Holly House (Barberry) 06/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Holly House (Barberry) 12 Ullet Road Liverpool Merseyside L8 3SR Lead Inspector Natalie Charnley Unannounced Inspection 1st November 2005 11:00 Holly House (Barberry) DS0000047970.V262393.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 (Barberry) DS0000047970.V262393.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 (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly House (Barberry) Address 12 Ullet Road Liverpool Merseyside L8 3SR 0151 727 5823 0151 283 3340 barberry@schealthcare.co.uk 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) Active Care Partnerships Limited Mrs Jane Dottie Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2004 Brief Description of the Service: Holly House (Barberry) is a large home located near the city centre of Liverpool, close to the Aigburth area. The home is owned by a large private company, Southern Cross, that have similar home both locally and in other areas of the country. The home is registered to provide 24 hour care to 15 young adults who have learning disabilities, however most residents present forms of challenging behaviour. The home is located in a large Victorian building and is on three levels. The home has 15 single bedrooms and a variety of communal space. The home has designated smoking areas for residents. The home has a large rear garden which residents have access to. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day. The inspector arrived at the home at 11.00 and left at 16.00.The inspector spoke with the manager and her deputy, 3 care staff and 6 residents. No visitors were available to speak to. The inspector completed the inspection by looking at the homes records, a tour of the building, formal and informal interviews and information from previous inspection reports. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas that needed covering were done so. Feedback was given to Manager during and at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that staff sign for all medications are signed for when given to residents. The environmental issues listed under standard 24 need to be addressed. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 6 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 (Barberry) DS0000047970.V262393.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 (Barberry) DS0000047970.V262393.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): 2 and 3 Residents have a detailed assessment completed before moving into the home to ensure they are kept safe. Staff meet the needs of residents and provide them with specialist support. EVIDENCE: The home does not admit any new residents without undertaking a pre admission assessment. These are very detailed assessments and contain information from a variety of sources, including the resident themselves. Details are held regarding physical and emotional support as well as any direct mental health needs. The residents then have their care plans based upon this assessment. Staff were observed to communicate well with residents and demonstrated the ability to manage a new resident who was very unsettled. Some of the residents at the home need specialist support from staff, which was also observed. This includes residents who need 1:1 or 2:1 staff support. Staff at the home have the skills and knowledge to care for the residents who live there. Nursing staff have a variety of qualifications including mental health nursing, general nursing and learning disability nursing. Care staff are similarly well trained. Local universities use the home to provide nursing students with clinical placements. Holly House (Barberry) DS0000047970.V262393.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): 6,7 and 9 Care plans are individual and outline the needs that service users have to ensure they receive appropriate care. Residents are given choice in all aspects of their daily life which promotes independence. Risks taken by residents are looked in detail and ensure that safety is maintained. EVIDENCE: A selection of care plans were sampled during the inspection. Plans were comprehensive and individual. Residents are involved in developing their care plans along with relatives and many other health professionals. All plans are updated on a regular basis. Details are recorded of social activities, clinical observations (such as blood pressure, pulse, weight etc), risk assessments and daily reports. These were well recorded, clear and accurate. Social services reviews and assessments were also contained in plans. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 10 Staff encourage, where possible, residents to make their own choices by offering them information and allowing them to ask questions. One resident stated “I have chosen how to decorate my bedroom” and went on to state how the home had supported her to do this. Another resident told the inspector “ I choose what I eat for my meals”, this was observed during lunch at the home. Risks that residents undertake are looked at in depth by the home, this includes when residents leave the home for short periods. Several residents had individual assessments completed as they are smokers and are not always aware of the potential hazards. Windows in the poolroom have also been replaced with reinforced glass following a risk assessment. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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): 11,12,15,16 and 17 Residents are given the opportunity to maintain and develop social, educational and practical skills to enhance their standard of living and potential for rehabilitation. Meals at the home are good, providing residents with balanced and varied diet. EVIDENCE: The home has a designated member of staff for 40 hours per week who is responsible for coordinating activities. There is no television in the communal lounge, but residents may have personal TV sets in their bedrooms. Some residents go to day centres and one resident is supported by the home and MENCAP to keep up a job. One resident is also developing independent living skills at a local collage. Staff and residents had joined in a Halloween party the day before the inspection and talked about recent trips out to the Wildflower Park and local shops. One resident commented “ we can go out with staff when we want and we are having some fireworks soon”. The home organises in house activities Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 12 such as pool and darts and have a large garden area with a nice decking area. Activities and social interaction is promoted by the home in order to let residents make the choice as to if and how they are going to move back into the community. Residents confirmed that visitors could come to the home at any time and could meet in private or communal areas. Care plans showed that families and friends are involved in the care of residents and that the home support and help maintain these links. Staff were observed knocking on bedroom doors before going in and talking to residents in a kind way. Those residents who are able are offered a key to their bedroom. Support is offered to residents as and when they need it and staff were noted to have good relationships with staff. The inspector observed lunch at the home which was a social and unhurried occasion. Meals are based on a monthly menu and are developed along with input from residents. Staff ask residents during the morning what they would like to eat and alternatives are offered if needed. Some residents are diabetic and need a special diet which is provided by the home. Residents are also enjoy an occasional take a way meal. One resident commented, “food here is good and we all enjoy it”. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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 and 20 Medication at the home is not always recorded correctly leaving residents at risk. The health needs of residents is monitored by the home to ensure residents remain supported. EVIDENCE: Residents at the home have access to a GP (General Practitioner) of their choice. The home employs a psychologist to support residents and a variety of other professional assist with input into care. Residents’ files show that the home monitor nutrition, how residents are moved, if they are at risk from pressure sores and if they suffer with seizures. Those residents who have problems with behaviour also have this charted to monitor for signs of change. Staff acknowledge that this multi agency work is needed to provide total care for their residents. The home has trained nursing staff who are responsible for giving out medication. Medication storage and recording was observed. Storage was satisfactory, however there were a number of errors in the recording of medication. This was addressed with the manager. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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): 22 and 23 The home has a good complaints procedure that protects the rights of residents. Staff have a good knowledge of adult protection procedures which protects service users from abuse. EVIDENCE: The home has a clear and accessible complaints procedure that can be obtained by residents or staff. No complaints had been received since the last inspection. All complaints are responded to within 28 days. The home has an Adult Protection policy that covers two local areas. Staff were aware of these documents and how to use them. Staff confirmed that they had received training on abuse and had undergone Police checks. The home have a policy where restraint is not to be used unless it has been risk assessed and recorded in the care plan. Staff have received training and ongoing support in the use of ‘non violence crisis intervention’. This means that they will try to support residents through talking and explaining situations that arise. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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): 24,26 and 30 The home needs continual monitoring of its environment to ensure it remains safe and suitable for residents. Residents bedrooms and personal and promote individuality The home is clean and hygienic providing a safe and protective environment for residents EVIDENCE: The home is located in an old building and keeping up to date with environmental issues is difficult and time consuming. A full tour of the building and outside grounds was undertaken and areas of repair identified. 1. The outside path area needs tarmacing to ensure all areas are wheelchair accessible and do not pose a hazard to residents. 2. The staff room needs urgent refurbishment 3. Bedroom 6 needs redecorating as wallpaper is falling off the walls 4. Independent living skills kitchen needs refurbishment The home has a maintenance person who works 40 hours per week and deals with minor repairs. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 16 Communal areas were bright and cheerful and free from offensive smells. The home was clean, tidy and warm. One resident stated, “ I like the home, it is comfy and nice”. A selection of bedrooms were also looked at with permission of the residents. Rooms were pleasantly decorated and had been personalised by residents. One resident stated, “ The home helped me buy my bedroom furniture” and went on to tell the inspector how she was encouraged to add personal touches to remind her of home. Residents can have a key to their bedrooms if they wish and are safe to do so; this is assessed by the staff. The manager explained that bedrooms are being redecorated as and when they are needed. A team of domestic staff are employed by the home to cover cleaning and laundry areas. Policies and procedures are available to all staff covering infection control and COSHH (control of substances hazardous to health). Despite the home having a very small laundry area, residents stated that washing is kept clean and is always returned quickly to bedrooms. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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 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 Staff at the home are competent in their jobs and have sufficient training to deliver good quality care. Staff checks are comprehensive ensuring the safety of residents EVIDENCE: The home has a qualified nurse on duty 24 hours per day at the home. Nurses are experienced and have a variety of qualifications in specialist areas. Some residents at the home require extra support from staff which the home provides. Staffing levels are continually monitored by the manager. Both the manager and deputy manager have supernumerary hours, which is an example of good practice. Staff at the home were happy with their jobs and felt that there were enough staff to look after residents who live there. One staff member stated “ we always have enough staff, even to support the more vulnerable residents”, another stated “we work well as a team” and went on to detail staff meetings that were held at the home. Observation of staff during the inspection showed that communication was good and that staff attended swiftly to residents needs. Staff at the home are checked against the POVA register (Protection of vulnerable adults) and undergo a full Police screen. Staff files sampled showed that staff have appropriate references and are subject to a comprehensive Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 18 induction period. Staff themselves felt that they were supported when they stated work in this specialist environment. A variety of training is undertaken by staff, paid for by a centrally held training budget. The home use a matrix to ensure all staff are kept up to date. Recent training had been given to staff on fire awareness and manual handling. 50 of care staff at the home currently hold an NVQ (National Vocational Qualification) in care. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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 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 The manager is competent and provides support for staff so they can provide a good standard of care. The home seeks the needs of staff, relatives and residents. These views are then acted upon swiftly. The home maintains the health and safety of staff and residents at all times, protecting them from harm. EVIDENCE: The home manager is a qualified nurse who is currently studying for a master’s degree. The manager has been in post for 4 ½ years and has remained updated on professional developments. From discussion and observation during the inspection, the manager is clearly aware of the wants and needs of the residents and the special support they require. Staff were positive about the home management stating it was “supportive” and “open”. Residents stated they “loved” the manager and stated that she always involves them in the running of the home. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 20 The home manager completes detailed monthly audits as part of monitoring quality. No formal quality assurance-monitoring questionnaire is currently uses, however the manager stated she is current developing a suitable tool to use with residents. This is being developed along side a local university. Residents meet every 6-8 weeks at present as part of a forum to discuss ideas and suggestions. The home has a set of policies and procedures in place to maintain the safety of staff and residents. These are updated on a regular basis. Staff receive appropriate training in this area. All certificates and insurances needed by the home were in place and the recording of accidents was satisfactory. Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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 3 x N/A Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x 3 LIFESTYLES Standard No Score 11 3 12 3 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly House (Barberry) Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x DS0000047970.V262393.R01.S.doc Version 5.0 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 2 Standard YA20 YA24 Regulation 13(2) 23(1) Requirement The registered person must ensure that all medications are signed for appropriately The registered person must ensure that the following maintenance issues are addressed: 1. The tarmac to the rear garden area is replaced 2. The staff room is refurbished 3. Bedroom 6 is re decorated 4. The independent living skills kitchen is refurbished Timescale for action 01/01/05 01/04/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holly House (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 (Barberry) DS0000047970.V262393.R01.S.doc Version 5.0 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. 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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