Inspection on 18/01/06 for Holly House (Barberry)

This inspection was carried out on 18th January 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 1 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) 01/11/05

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 18th January 2006 11:00 Holly House (Barberry) DS0000047970.V280386.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 (Barberry) DS0000047970.V280386.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 (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 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 Ltd Mrs Jane Dottie Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 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 and 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.V280386.R01.S.doc Version 5.1 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 14.30.The inspector spoke with the manager, 4 members of staff and 4 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. The home has been assessed on all the core standards for the 2005/06 inspection year. One requirement regarding maintenance remains outstanding. What the service does well: What has improved since the last inspection? What they could do better: Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 Page 6 There remains some outstanding maintenance issues which the home have started to progress. This is in relation to developing the staff room and independent living skills kitchen and re tarmacing the back path. 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.V280386.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 (Barberry) DS0000047970.V280386.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): None of the above standards were assessed in full during this inspection EVIDENCE: Holly House (Barberry) DS0000047970.V280386.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 Care plans are individual and outline the needs that residents have to ensure they receive appropriate care. EVIDENCE: Three care plans were sampled during the inspection. Plans were comprehensive and individual. There was evidence in place to show that the home monitor and record behaviour patterns and have a ‘clinical event history’ information sheet. This details areas that staff need to be aware of in order to support and safely care for residents. One resident was being cared for on a special mattress. Records showed why this decision had been made and clearly outlined a protocol for staff as to when the resident is to have periods of rest. Another resident was suffering with inappropriate urination. A new care plan had been set up with the resident and other professionals to deal with the problem. All plans are updated on a regular basis and details are recorded of social activities, clinical observations (such as blood pressure, pulse, weight etc), risk assessments and daily reports. One resident commented “ we join in with all parts of planning care”. Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 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): 13 The home link in with the local community to help provide residents with a diverse and fulfilling lifestyle EVIDENCE: Staff at the home spend time outside of the home supporting residents in accessing the local community. Residents can access all community services such as libraries, day centres, and cinemas and pubs. A risk assessment is carried out to ensure these trips are safe before they happen. Transport is arranged by the home and is tailored to suit each individual trip. One resident living at the home is a Muslim who requires a special diet. The home have organised this by involving the residents family and the Imam (a muslin leader) from the local mosque. The home buys special halal meat (this is meat killed in a specific way) for the resident from the local supermarket. The home also has two Muslim members of staff who help in advising on religious practices and also let the resident walk bare foot as part of his religion. Two other residents are supported by staff to attend a local church for mass. Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 Page 11 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 and 20 Residents are supported to decide where and when their care is given which helps promote independence and choice. Medication practices have improved, ensuring residents safety is maintained EVIDENCE: Residents are allocated a named nurse and key worker when they move into the home. These members of staff act as points of contact to discuss care issues or personal issues a resident may have. Residents have some input into choosing who is allocated to them, however staff are moved from one resident to another from time to time so residents don’t become too dependent on one person. Residents are asked where they wish to go if a doctor or other professional visits, this is usually to the privacy of their bedroom, however some prefer the office so staff can support them. The manager has recently purchased two sets of curtains for the office window that looks into the dining room in order to maintain residents privacy. Medication records and storage were checked at the home. Records were well maintained by staff and had improved since the last inspection. No controlled drugs were stored at the home, however suitable storage is available for staff. Two nurses are documenting when drugs are returned and stock levels of medications were satisfactory. Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 Page 12 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): None of the above standards were checked in full during this inspection. EVIDENCE: Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 Page 13 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 The home needs continual monitoring of its environment to ensure it remains safe and suitable for residents The home is clean and hygienic providing a safe and protective environment for residents EVIDENCE: In the process of speaking to residents, a tour of the home was carried out. The home has started to redecorate bedroom 6 and have put new flooring into bedroom 27, in order to provide a comfy place for residents to live. One resident asked the inspector to look at the flooring in the downstairs corridor and by the back door as she felt it needed replacement. The area by the back door was heavily stained with cigarette burns as some residents smoke in this area, despite having a smoking room provided on the first floor. The manager must decide if this is a suitable place for residents to smoke and look into replacing the flooring. The manager explained how she had addresses the requirements for maintenance made during the last inspection. The estates manager for the company is looking into re tarmacing the back path and decorating the staff room. Quotes are currently being sought regarding Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 Page 14 refurbishing the independent skills kitchen; these areas will be re assessed during the next inspection. All other areas of the home were clean and tidy. Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 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 and 34 Staff at the home are competent in their jobs to deliver good quality care. Staff checks are comprehensive ensuring the safety of residents EVIDENCE: The home has a close staff team who have a variety of qualifications. The staffing rotas showed that some agency staff had been used to cover recent sickness, but that staffing levels were being kept at a good level to make sure residents are kept safe. During the inspection, one resident was having an episode of very challenging behaviour. Staff were observed to manage this very well, keeping each other and the resident safe and supported at all times. Residents commented, “staff here are great” and “they are very friendly”, they also stated that staff were always there when they needed them. The home is also a placement used by local universities who train nurses. The home is audited by the collages on a regular basis to make sure the home offers a suitable placement. The home had only take on member of staff on since the last inspection. The staff file showed that two written references had been taken up as had a police and POVA (protection of vulnerable adults) check. All the necessary documents were in place to ensure that the staff member was qualified and suitable to work with this client group. Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 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): 42 The home maintains the health and safety of staff and residents at all times, protecting them from harm. EVIDENCE: Accident records were well recorded by staff and detailed what had happened to residents. The home manager monitors all accidents to ensure that they have been dealt with appropriately and puts in place changes if they are needed. The home has safety certificates in place to cover gas, electric and portable appliances (e.g. lamps and televisions). These checks are carried out at regular intervals to ensure the home is a safe place to live. Staff confirmed that they had recently had a fire drill and evidence on staff files showed that the fire drill is covered by all new staff during their induction. The audits for maintenance, catering and housekeeping were looked at and showed no areas for concern. Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 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 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X X X X X X X 3 Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 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. 21 Standard YA24 Regulation 23(1) Requirement The registered person must ensure that the following maintenance issues are addressed: The tarmac to the rear garden area is replaced The staff room is refurbished Bedroom 6 is re decorated The independent living skills kitchen is refurbished Remains outstanding from the previous inspection, however the home have demonstrated that they have started to process these issues Timescale for action 01/07/06 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 YA24 Good Practice Recommendations The manager may wish to review if residents can smoke in the back door area and give strong consideration to replacing the flooring that has cigarette burns. Holly House (Barberry) DS0000047970.V280386.R01.S.doc Version 5.1 Page 19 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.V280386.R01.S.doc Version 5.1 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. 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