Inspection on 07/11/05 for Holly House (Beechley)

This inspection was carried out on 7th 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly House (Beechley) 17/07/06

Holly House (Beechley) 02/03/06

Holly House (Beechley) 21/10/04

Holly House (Beechley) 06/05/04

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 (Beechley) Harthill Road Liverpool Merseyside L18 3HU Lead Inspector Natalie Charnley Unannounced Inspection 7th November 2005 11.00 Holly House (Beechley) DS0000047937.V265004.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 (Beechley) DS0000047937.V265004.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 (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly House (Beechley) Address Harthill Road Liverpool Merseyside L18 3HU 01325 351 100 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) beechley@schealthcare.co.uk Active Care Partnerships Limited Mrs Anne Fitzpatrick Care Home 30 Category(ies) of Learning disability (20), Physical disability (10) registration, with number of places Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2004 Brief Description of the Service: Holly House is located in Liverpool and is within the Allerton area. The home is owned by a large organisation, which has similar homes both locally and nationally. The home is easily accessible by bus and car and is a 3-story house within large grounds. It accommodates up to 30 younger adults. Nursing and social care is provided by the home and the home cares for adults with a learning or physical disability. Accommodation consists of 26 bedrooms, 22 single and 4 doubles. 19 of the rooms have en-suite facilities. Other bedrooms have hand-washing basins. Due to the age of the building, continuing environmental repairs need addressing by the home. Holly House (Beechley) DS0000047937.V265004.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 to 4 care staff, the deputy home manager, a registered nurse, 2 visitors, a social worker and 7 residents. 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 the deputy 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 home must continue to develop and repair the identified areas to the environment. The areas highlighted in the last report regarding ventilation and light have been partially met but need to be developed further. The home must produce an action plan for environmental developments to the home as some requirements have been in place for a long period of time Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 6 Accidents must be stored confidentially Staff must ensure that they record all medication correctly. 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 (Beechley) DS0000047937.V265004.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 (Beechley) DS0000047937.V265004.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): 1,2 and 5 The service user guide and statement of purpose are not in a suitable format for service users to make an informed choice. Contracts for residents are clear and accurate, providing safety for residents. Residents have a detailed assessment completed before moving into the home to ensure they are kept safe. EVIDENCE: All residents have a pre-admission assessment completed by staff before they move into the home. This document is based on physical, social and emotional details as given by the resident or their family. The pre admission assessment is then used by staff to formulate a care plan for residents. When residents are admitted by a social worker, their assessment documents are also used. Residents have access to the home statement of purpose and service user guide. This is a detailed document which covers areas such as staffing, how to make complaints, room sizes and fees. The document was found to be in a format that was not appropriate for the residents who live at the home. Print was small and no colour or pictures were used. The home needs to work on how to make these documents more ‘user friendly’. Individual residents are given a contract by the home when they move in. These are clear and had been signed by residents or their families, however contained, as did the service user guide, details of the previous regulatory body and not the Commission for Social Care Inspection. These small changes need to be added to documents to update them. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 9 Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 10 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: All residents living at the home have an individual plan of care. Seven of these were looked at during the inspection. As part of care planning, the home use ‘essential lifestyle plans’ which details how individuals can achieve their personal goals and admissions. These documents need to be developed further to ensure residents are included in their development and that they use colour, pictures or photographs to make them easy to read and understand for residents. Two of the care plans sampled had details of medical diagnosis that were not available in the assessment and only two had signatures of residents or their families to stated they had been involved in the care planning process. For residents who have no next of kin, the home has details of local advocacy services. All plans showed that they were updated on a regular basis. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 11 The home assesses all risks that are taken by residents. These are also updated regularly. Areas such as falls, moving and handling and nutrition are looked at. Residents who smoke also have a special assessment in place. Residents living at the home are supported and encouraged to make independent decisions. One resident stated, “ I can chose different activities to join in with and which trips out I go on”. Residents complete a monthly feedback sheet that details what they have enjoyed and what they haven’t. This allows residents to act on their experiences to choose what they wish to participate in the following month. Residents also meet monthly in a forum to choose activities and to plan future developments at the home. One visitor stated “my son is encouraged to make choices every day, he has developed this skill since moving into the home”. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 12 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): 11,13,14,15 and 16 Residents are given the opportunity to maintain and develop social, educational and practical skills to enhance their standard of living and potential for rehabilitation. EVIDENCE: The home has two designated activity staff that work during the week. Residents have a special activity area that displays a variety of work that they have produced. During the inspection, residents were observed joining in with an art class and waiting to go out on a trip for which they have a mini bus. Details of who joins in with activities is recorded in personal files and a general weekly plan of activities is followed, however sometimes changes if residents choose to do something else. Residents spoken to spoke about trips that they had enjoyed to ‘ Anfield’, ‘local pub’ and ‘the football museum’. One resident participates in ‘a chance to work’, which is a local collage scheme with a work placement. One resident stated, “ We do a lot of different things here” and went on to talk about how he enjoyed having his work displayed on the walls. Details are available for all resident about activities going on in the local community. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 13 A local social worker visiting the home was very complementary about the standard of care offered by staff and stated “ I am always welcome here and visit at different times of the day”. A visitor spoken to stated the same adding “ if I can’t visit, staff are always available to tell me about my son over the phone. Sometimes I just need a little reassurance”. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 14 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 Residents are given choices as to how they are cared for Medication at the home is not always recorded correctly leaving residents at risk. The health needs of residents are monitored by the home to ensure residents remain supported. EVIDENCE: Observation at the home demonstrated that residents were offered choice in a variety of their daily tasks. This is supported by the residents forum where residents can offer their opinions and ideas, and by the ‘feedback sheet’, which is completed monthly. Details of residents choices, likes and dislikes are detailed within their essential lifestyle plan. One resident stated, “I can chose what time I get up and go to sleep”, another stated “I can eat when I want to”. The home uses many other health professionals to care for residents. Records show that GP’s (general practitioners), psychiatrists, social workers and opticians have been used. Residents and staff confirmed all visits could take place in private, this was observed during the inspection. As the home employs qualified nurses, residents physical health is also closely monitored and recorded. Residents can access local NHS facilities and are supported to attend outpatients appointments by staff. Records of health care of kept in care plans and diaries and are well documented. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 15 Medication at the home is given out by the nursing staff. Records were mainly well recorded. There were a few gaps in recording of medications and staff that had handwritten medication instructions had not dated or double signed records. A medication audit is completed by the home on a monthly basis and the local pharmacist reviews medication on a regular basis. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 16 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 do not have a good knowledge of adult protection procedures, which leaves residents at risk. EVIDENCE: The home has a complaints procedure that is within the service user guide. This must be amended to show details of the Commission for Social Care Inspection. The home may wish to produce this document in a style that is more appropriate to the residents and in larger text. Residents and families spoken to knew how and who to make a complaint to if needed. One complaint had been recorded since the last inspection and had been dealt with swiftly by the home. Six staff files were checked. These showed that staff had been police checked and checked for registration on the POVA (Protection of vulnerable adults) register. Staff had not received training on abuse awareness and were not sure of the local policies that are in place and how allegation of abuse are managed. This must be addressed by the home. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 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 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: Following the last inspection the home was given several requirements regarding the environment. Some of these areas have been addressed, however some remain outstanding, these are highlighted under the requirement section further in the report. The home continues to experience continuing problems with the environment, however the company are looking into re locating the home in the future to make it more suitable for the residents. A full tour of the inside and outside of the home was undertaken. Bedroom 17 was found to have a window that was held open with a plastic bottle. The upstairs shower room had mildew on the ceiling and had a musty smell. Work was in progress on levelling the bin storage area. Staff and residents were able to indicate which bedrooms had been re decorated. Residents spoken to were Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 18 happy with the communal and private areas of the home and felt their accommodation was “warm and nice”. The home was clean and tidy on the day of the inspection. One visitor commented that the home was “ very clean and always pleasant”. The home have a comprehensive policy on infection control and have a contract with a clinical waste company to ensure all waste products are removed safely. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 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): 32,33,34 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 The home has sufficient numbers of staff employed to ensure the safety of residents EVIDENCE: The home employs trained nurses and care assistants to care for residents. These staff are supported by activity staff, cleaners, a chef, a laundry assistant and a handyman. The staff rotas show that the home employ enough staff to provide the care needed by residents and only use agency staff on a few occasions, usually on nights. Care staff are supported by the home to completed their NVQ’s (National Vocational Qualification). The visiting social worker spoke highly of the staff stating they were “ supportive” and “very good at their jobs”. Staff undertake a variety of training and receive a comprehensive induction. Recent training has been completed in health and safety and food hygiene. Management use a training matrix to make sure all staff are kept up to date with training. Observation of staff showed that they were skilled and confident in dealing with residents living at the home. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 20 Six staff files were sampled at random. These showed the home are checking references and criminal records and implementing contracts and supervision. All registered nurses have up to date PIN numbers showing they are registered with the Nursing and Midwifery council. One staff member who was new to the home explained that she had been well supported and “ had a thorough introduction into the home and residents”. She had been shown basic manual handling techniques (on the day of the inspection) and had the home policies and procedures explained. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 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): 39 and 42 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: Residents participate in the running of the home via a residents forum which is held on a regular basis. Details of these meetings are well recorded. Residents can choose what they wish to discuss which includes food, activities and future developments for the home. The forum is supported by staff members for those residents who need a little extra help in joining in. Residents and their families are continually asked for their ideas and a ‘service user survey’ is completed and used by the management team. Visitors at the home also confirmed they are asked for ideas and suggestions. The home has a comprehensive file of policies and procedures which staff have access to. This covers all aspects of health and safety. Audits take place on a regular basis to ensure standards are maintained. Accidents recorded at the Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 22 home are kept in a communal book which does not comply with the Data Protection Act. This was explained to the manager at the time of the inspection. The home has up to date safety checks and certificates in place. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly House (Beechley) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000047937.V265004.R01.S.doc Version 5.0 Page 24 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 YA1 Regulation 4(1) Requirement The registered person must ensure that the home statement of purpose and service user guide are in a format suitable for residents and that details of the Commission for Social Care Inspection are included The registered person must ensure all medications are recorded correctly. All medications that are handwritten must be double signed and dated. The registered person must ensure that all staff has abuse awareness training and that they are aware of the local adult protection policies. The registered person must ensure that bedroom 1- the broken chest of draws are repaired or replaced. The ceiling plaster is cracked and peeling and requires attention. This is outstanding from the previous inspection The broken chest of draws to bedrooms 2,4,9,13 and 26 are replaced. Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 25 Timescale for action 01/01/06 2 YA20 13(2) 01/12/05 3 YA23 18(1) 01/02/06 4 YA24 23(1)(2) 01/01/06 This is outstanding from the last inspection The registered person must ensure that all bedroom furniture is replaced, as it is over 10 years old. This is outstanding from the last inspection The registered person must ensure that an alternative storage space is found for hoists This is outstanding since the last inspection The registered person must ensure that the laundry room is suitable for staff and residents to launder their clothes. This is outstanding since the last inspection The registered person must ensure that room 7 has the window fixed so it doesn’t need holding open with a bottle The upstairs shower room must be repaired to ensure mildew and the musty smell is removed. The registered person must provide the inspector with a plan for environmental development at the home. The registered person must ensure that all accidents are stored to maintain the confidentiality of the residents. 5 YA42 13(4)(a) 01/12/05 Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 26 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 Refer to Standard YA6 YA11 Good Practice Recommendations The home may wish to continue to develop essential lifestyle plans to make them more user friendly and colourful The home may wish to develop a provision of a rehabilitation kitchen so residents can have the opportunity to learn and use domestic skills This is outstanding form the last inspection Holly House (Beechley) DS0000047937.V265004.R01.S.doc Version 5.0 Page 27 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. 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