The Hollies Care Home Service Adults

The HolliesCare Home Service Adults4 Woodhall RoadColintonEdinburghEH13 0DXTelephone: 0131 466 6976

Type of inspection: Unannounced

Inspection completed on: 3 July 2014

ContentsPage No

Summary 31 About the service we inspected 52 How we inspected this service 73 The inspection 114 Other information 275 Summary of grades 286 Inspection and grading history 28

Service provided by:Tiphereth Limited

Service provider number:SP2003002619

Care service number:CS2004073783

If you wish to contact the Care Inspectorate about this inspection report, please callus on 0845 600 9527 or email us at [email protected]

Inspection report continued

The Hollies, page 2 of 30

SummaryThis report and grades represent our assessment of the quality of the areas ofperformance which were examined during this inspection.

Grades for this care service may change after this inspection following otherregulatory activity. For example, if we have to take enforcement action to make theservice improve, or if we investigate and agree with a complaint someone makesabout the service.

We gave the service these grades

Quality of Care and Support 6 Excellent

Quality of Environment 5 Very Good

Quality of Staffing 6 Excellent

Quality of Management and Leadership 5 Very Good

What the service does wellThe Hollies provides a very homely service. All the residents said they were very happythere.

They were fully involved in making choices about their care, support and how theywanted staff to help them manage their lives.

What the service could do betterSome records could be improved to ensure that the discussions that take place arewritten down in enough detail.

What the service has done since the last inspectionThe service continues to assist the residents to build upon their individual strengths,based upon their choices, wishes and needs.

All the residents continue to be involved in the development and improvement of thehome and the wider Tiphereth community.

New risk assessments are being developed. These will provide better informationabout how to support people to manage risks.



A medication system has been introduced. This should improve records and minimisethe possibility of mistakes being made. Medication will also be audited.

ConclusionResidents are involved in all aspects of the care home and the wider community ofwhich it is a part.

We saw that the residents were well-supported by the staff team, who live withresidents in the home, to make choices in all aspects of their daily lives, to maintainand develop skills and potential and to be included in the local community.



1 About the service we inspectedThe Hollies is a care home which provides care to a maximum of four adults who havelearning disabilities. Four residents were using the service at the time of theinspection visit.

The home is close to local amenities and public transport. It is a spacious propertywith bedroom and bathroom/ toilet facilities on three floors althoughaccommodation for residents' use is mainly on the ground floor level. Staffaccommodation is also provided in the home. There are gardens surrounding thehome which are terraced to the side and rear of the building.

The service is managed by Tiphereth Ltd as part of care home and support serviceswhich they provide in the local area. Tiphereth Ltd is a member of the Association ofCamphill Communities which share the same guiding principles and philosophy ofRudolph Steiner.The guiding vision of Tiphereth says that 'in living, working and growing together weoffer a wide variety of services for adults with learning disabilities where the qualitiesof openness, respect, trust and care are nurtured'.The Care Inspectorate regulatescare services in Scotland. Prior to 1 April 2012, this function was carried out by theCare Commission. Information in relation to all care services is available on ourwebsite at www.scswis.com

This service was previously registered with the Care Commission and transferred itsregistration to the Care Inspectorate on 1 April 2011.

Requirements and recommendations.

If we are concerned about some aspects of a service, or think it needs to improve, wemay make a recommendation or requirement.

- A recommendation is a statement that sets out actions the care service providershould take to improve or develop the quality of the service based on best practice orThe National Care Standards.

- A requirement is a statement which sets out what is required of a care service tocomply with the Public Services Reform Act (Scotland) Act 2010 (the Act) andsecondary legislation made under the Act, or a condition of registration. Where thereare breaches of Regulations, Orders or Conditions, requirements may be made.Requirements are legally enforceable at the discretion of the Care Inspectorate.



Based on the findings of this inspection this service has been awarded the followinggrades:

Quality of Care and Support - Grade 6 - ExcellentQuality of Environment - Grade 5 - Very GoodQuality of Staffing - Grade 6 - ExcellentQuality of Management and Leadership - Grade 5 - Very Good

This report and grades represent our assessment of the quality of the areas ofperformance which were examined during this inspection.

Grades for this care service may change following other regulatory activity. You canfind the most up-to-date grades for this service by visiting our websitewww.careinspectorate.com or by calling us on 0845 600 9527 or visiting one of ouroffices.



2 How we inspected this service

The level of inspection we carried outIn this service we carried out a low intensity inspection. We carry out theseinspections when we are satisfied that services are working hard to provideconsistently high standards of care.

What we did during the inspectionWe wrote this report following an unannounced inspection. The inspection wascarried out by one Care Inspectorate Inspector. This took place on 2 July 2014. We toldthe Manager what we found at the inspection 3 July 2014.

As requested by us the care service sent us an annual return. The service alsocompleted a self assessment form.

In this inspection we gathered evidence from various sources including the relevantsections of policies, procedures and other documents including:

- Sampled support and care plans- Reviews of support and care plans- Risk assessments- Support agreements- Communication books and diaries- Team meeting minutes- Recruitment records- Training records- Support and supervision records- Appraisal records- Staff training records- Incident and accidents- Complaint records- Quality assurance information- Complaints policy- Minutes of meetings for People using the services

Discussions with:

The Registered ManagerThe House ParentsStaff.



We went to one resident's review, met two parents and took part in the evening mealwith residents and staff.

Grading the service against quality themes and statementsWe inspect and grade elements of care that we call 'quality themes'. For example,one of the quality themes we might look at is 'Quality of care and support'. Undereach quality theme are 'quality statements' which describe what a service should bedoing well for that theme. We grade how the service performs against the qualitythemes and statements.

Details of what we found are in Section 3: The inspection

Inspection Focus Areas (IFAs)In any year we may decide on specific aspects of care to focus on during ourinspections. These are extra checks we make on top of all the normal ones we makeduring inspection. We do this to gather information about the quality of these aspectsof care on a national basis. Where we have examined an inspection focus area we willclearly identify it under the relevant quality statement.

Fire safety issuesWe do not regulate fire safety. Local fire and rescue services are responsible forchecking services. However, where significant fire safety issues become apparent, wewill alert the relevant fire and rescue services so they may consider what action totake. You can find out more about care services' responsibilities for fire safety atwww.firelawscotland.org



What the service has done to meet any recommendations we madeat our last inspectionWe made one recommendation at the last inspection.

1. The service should ensure that it can demonstrate audits of the quality assurancesystems in place have been carried out and that any improvements are noted. Theservice should ensure that any improvements are fed back to all those who havecontributed to assessing and improving the service.

National Care Standards, Care homes for people with a learning disability, Standard 5- Management and staffing arrangements.

We found that more auditing and checks were taking place and that the Manager hadwritten reports for the Directors of the organisation, to give an overview of, forexample, accidents.

We saw that the medication was audited (with individual agreements wherenecessary) and this should help ensure the service is aware of medication in stockand what it has returned to pharmacy.

Enough progress has been made to meet the recommendation. However the Managershould ensure that notes and records kept by the service are written in enough detail.

The annual returnEvery year all care services must complete an 'annual return' form to make sure theinformation we hold is up to date. We also use annual returns to decide how we willinspect the service.Annual Return Received: Yes - Electronic

Comments on Self AssessmentEvery year all care services must complete a 'self assessment' form telling us howtheir service is performing. We check to make sure this assessment is accurate.We received a fully completed self assessment document from the service provider.We were satisfied with the way the service provider had completed this and with therelevant information they had given us for each of the headings that we grade them



under.

The service provider identified what they thought they did well, some areas fordevelopment and any changes they planned. The service provider told us how thepeople who used the care service had taken part in the self assessment process.

Taking the views of people using the care service into accountWe sent out 4 Care Inspectorate Care Standard Questionnaires and 3 were returned tous before the start of the inspection. Everyone agreed that 'overall, I am very happywith the quality of care and support this service gives me'.

Taking carers' views into accountWe met two parents during the inspection. Both were very pleased with the serviceand the quality of the support given. They agreed that although some of the staffchanged because their time in the service was limited this did not create difficultiesin continuity because house parents knew residents well and helped settle newworkers quickly.

The parents also said that their children now welcomed the changes as it meant theymet new people from different parts of the world. They also saw this as a positivedevelopment for their child, as they was better able to cope with change.



3 The inspectionWe looked at how the service performs against the following quality themes andstatements. Here are the details of what we found.

Quality Theme 1: Quality of Care and SupportGrade awarded for this theme: 6 - Excellent

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the care and support provided by the service.

Service strengthsThe service offered excellent opportunities for residents and their families toparticipate in assessing and improving the quality of care in the home and toparticipate in making decisions about all aspects of the service and organisation.

Within the home the methods used to gather residents and families views included:

* taking part in reviews of the care plan and risk assessments* regular house meetings* individual meetings* daily discussions at meals* newsletters* verbal comments* telephone and email comments from parents and families.

We saw that a quality assurance survey had been carried out in late 2012, the resultsanalysed and feedback to participants. We were told this was to be repeated later in2014.

There was a Service User Participation Process. This stated that 'the views of usersare valued and encouraged at every opportunity'. The document described in detailhow people could take part in the organisation at every level. This meant thateveryone was aware of the expectations that users' views would be listened to andshow this would happen.

The governance, management and community structures of Tiphereth were described



as tree-like. This provided a picture of how all parts of the organisation workedtogether. This also showed where people using the service and their families/relatives were part of the forums and councils that contributed to the decision makingprocesses of the whole structure.

One resident said they attended the Council meetings regularly. We were told theywere able to ask questions and promote the views of the others living at The Hollies.We also saw that the residents had been asked for their views about developments inthe wider organisation. For example, discussions had taken place at people's' workplace. This helped increase the opportunities for people to have a say in how servicescould be improved.

This also meant that residents and other service users were represented within thewhole and could use these opportunities to feed any issues or concerns into decisionmaking. This gave people the chance to pass on the views of others in the house theyshared. We found that big decisions were taken slowly and thoughtfully so thateveryone's views could be heard.

Residents were encouraged to review their own care plans and where possible writetheir own directions for staff. One example we were shown explained in detail howthe person wanted their care given. This gave a very personal feel to the plan.

We saw that care plan reviews took place at least six monthly. This gave residents achance to express their views about the care more formally. We saw that peopleinvolved with each individual were invited, including the family. We saw that wherethe family could not attend the review decisions about care could be put off until theyhad been contacted, if appropriate. This meant everyone had the chance to have theirsay and reach decisions based on a consensus.

We sat in on one review during the inspection. We saw that the person using theservice was asked to give their opinion about all the parts of the care and supportprovided, changes they would like and when they wanted these to start. This seemedto work really well for everyone involved.

In the three Care Inspectorate Care Standard Questionnaires sent back to us all theresidents agreed that they had enough of a say in writing their personal plan. Twopeople said they had a say in how the service was run all of the time and one saidsome of the time.

We spoke to parents and they said that residents had a lot of say in how their homewas run. They said they were kept well informed about any issues or concerns andwould contact the house parents or Manager if they had any worries.

Residents we spoke with said they thought they were listened to and that their viewswere respected in deciding how the home ran on a daily basis. We saw that staff



worked very flexibly to meet people's' needs, whether for care or activities, over thecourse of the day.

Areas for improvementAt the last inspection we saw that the service would plan more house meetings andrecord minutes. We saw that two meetings had taken place this year and noteswritten down. A wide range of topics had been discussed. The service should continueto develop this approach.

Grade awarded for this statement: 6 - Excellent

Number of requirements: 0

Number of recommendations: 0



Statement 3We ensure that service users' health and wellbeing needs are met.

Service strengthsAs an organisation, Tiphereth offers a number of meaningful work activities for peopleto participate in. Some of these take place in the house. Others are provided by itsday service. These include artistic and weaving projects, kitchen activities, gardeningand conservation work. Staff told us how they supported people to develop their skills,confidence and abilities working in the different settings.

Residents took part in daily individually designed programmes to meet their needs.They were also supported to attend other resources where a particular interest couldbe met better, or to take part in college courses.

Residents told us about how they enjoyed the work they did and what they thoughtthey got from it.

People using the services had individual care and support plans. These containeddetailed information about the care and health needs each person had, showingwhich health professional and staff member was responsible for the care. Eachperson had a key worker who was responsible for keeping care plans up to date andensuring that they and, where appropriate, their relatives or advocate, were involvedin this process. People we spoke with said their relatives were invited to reviews andwe saw that their participation was recorded

We looked at two plans. These showed how staff helped people using the service tomeet their health needs. These included supporting people to make appointmentswith their GP or other health professionals such as speech and language therapistsand dentists. Staff helped people get to appointments and supported people tomanage the ones they found difficult, such as going to hospital.

People using the service and families told us:

'so lucky to have this service''the service is wonderful''I can talk to the staff at any time'.

People using the service said they contributed to their own support planning. We sawthat the section in one care plan entitled 'things my worker needs to know' waswritten by the resident. The Manager told us that this had been updated by theresident. This showed how the resident wanted their care provided and the thingsthat they expected from staff.

Staff we spoke with said they knew the health needs of people using the service.



They said they felt confident in their work and that they were well supportedthemselves by the house parents and others in the team. They found the care planswere really helpful and gave a good introduction to each person, and the ways towork with them. Staff were able to discuss health problems that had affected peopleusing the service. We saw that some plans had very specific directions about how towork with people's' behaviours.

We saw that some specific training, for example, in epilepsy management wasprovided quickly, to reassure the residents and help build the staff's confidence.

In one Care Inspectorate questionnaire one parent said that if the resident's (named)'behaviours would indicate if she was worried or scared, the House Parents and co-workers all have a terrific understanding of (name) and would immediately sort outanything which made (name) anxious'.

The organisation had a medication policy and procedure and the staff receivedtraining in medicines administration. These helped staff working in the home managemedication safely with each resident. Where possible, and with the agreement oftheir GP, residents were supported to manage their own medication and be asindependent as possible.

Staff said they were trained to carry out any specific procedures to meet people's'needs, such as helping manage their epilepsy.

Areas for improvementLiving as a community and the family-inspired way of providing the service tries tocreate 'a mutually supportive environment in which every person feels respect, valueand inclusion in the shaping of our community life and care provision'. Because ofthis ethos the service keeps few notes about the care and support people receive on adaily basis.

At the last inspection we noted the service had started keeping monthly needssummaries of each person's health and well-being in line with Care inspectorateguidance. We thought that the service should continue to ensure it keeps adequatenotes of progress to meet people's' needs.






Quality Theme 2: Quality of EnvironmentGrade awarded for this theme: 5 - Very Good

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the environment within the service.

Service strengthsThe strengths we saw in statement 1.1 may also apply here.

In the Care Inspectorate Care Standard questionnaires all of the residents said thatthey were involved in choosing how their home and rooms were decorated. They allsaid they liked the decoration. We saw that rooms were highly personalised by theirowners.

Residents had created a range of arts and crafts pieces including weavings, tapestry,painting and woodwork. Artworks appeared throughout the house. The hangingsculpture in the kitchen had changed once more. These added personal touches tothe whole environment.

Parents told us they couldn't think of any changes they would want. One said they'just loved the place'.

Areas for improvementThe service should continue to involve residents and their families in assessing andimproving the home environment.






Statement 2We make sure that the environment is safe and service users are protected.

Service strengthsWe saw that the home was spacious, clean and tidy. Corridors were kept clear andthere was access to the outside spaces. There was ample household equipment andfacilities for residents to use. These helped ensure that the home was a pleasantplace to live in. The house had been adapted to ensure people could get around itindependently. Bedrooms were furnished and decorated to reflect residents'individuality and choice.

The Manager told us that staff induction to the service included health and safety,medication management, risk assessment, fire safety and Adult Support andProtection. This was some staff's first experience of work and living in other people's'homes so emphasis was placed on how staff must behave within the home, showingrespect for the residents, the environment and each other. We found that there wasclear guidance for staff to ensure residents were safe and well supported.

Medication was stored in locked cabinets as necessary. If people were able to managetheir own medication they had storage cabinets in their own rooms. Some residentshad epilepsy and where possible were supported to manage their own rescuemedication. This helped residents develop their independence. Where staffadministered medication they had to undertake a competency assessment beforeundertaking this task. We asked staff about this and they told us they felt comfortableadministering medication. They said this work fitted into the daily routines of theresidents.

Residents liked to know that all staff were trained in administering medication,especially for epilepsy. This was reassuring for them.

We saw that the service had introduced a new medication recording and auditingsystem. This was being tailored to meet the needs of residents and the service. Wethought this was an improvement on the previous system.

There were records of gas and electrical equipment tests. Fridge and freezertemperatures were recorded and the temperatures of food checked.

All staff were expected to ensure that the environment was safe for residents and itwas emphasised that this was their responsibility. Specific tasks were allocated asrequired. House parents checked that the environment was kept to a very goodstandard.

Areas for improvementSince the last inspection the service had tried to improve the recording of medicationcoming into and out of the service, where it was returned to the pharmacy. The



service had used the local pharmacy and consultancy to develop a robust system. Thishas now been introduced to all the care homes in Tiphereth. We will see how this hasprogressed at the next inspection.

We discussed risk assessments with the Manager. At previous inspections we hadlooked at how risk assessments could meet the needs of people and service better.Since then the service had adopted a more person centred approach and had testedthis out with staff, to positive feedback. The new system would give staff improvedinformation about how to support people to manage risks. This is about to beintroduced and we will see what progress has been made at the next inspection.

Staff in the service come from many different cultural backgrounds. This is an obviousstrength and people using the service enjoyed hearing about the places staff camefrom. However this is also a challenge for the house parents who need to make surethat instructions and requests are understood and acted upon, to ensure theenvironment is kept safe.

Grade awarded for this statement: 5 - Very Good





Quality Theme 3: Quality of StaffingGrade awarded for this theme: 6 - Excellent

Statement 1We ensure that service users and carers participate in assessing and improving thequality of staffing in the service.

Service strengthsThe comments made in statement 1.1 may also apply here.

In the Care Inspectorate Care Standard Questionnaires two residents said they wereinvolved in choosing staff some of the time and one said they were not. Three peoplesaid they had a key worker and one had chosen who that was. Another said that they'did not mind not having a choice'.

The Manager told us that residents were involved in choosing staff wherever possible.However this must be meaningful to the individual so not all residents took part. Inaddition because some of the volunteers came from overseas the selection processdid not allow resident involvement. However they also told us that in future the use ofelectronic communications such as 'Skype' would be considered and this could enableresidents to take part.

We have said elsewhere that residents wrote their own support plans. These gaveclear directions and residents were able to direst staff in the ways to work best withthem and improve their own work practices. We also saw that residents had a key rolein the reviews of their support plans.

People using the service were encouraged to make their views known about staff inother ways, such as at meal times. This was all about helping new staff work withthem better. Having these comments of observing practice helped the house parentdiscuss issues with staff.

One resident had a particular interest in re-cycling everyday waste. They haddeveloped a system for managing this in the house and had been asked to help trainother staff and people using the service in other parts of Tiphereth. We thought thiswas a very good piece of work with this person.



Areas for improvementThe service should continue to involve residents and families/carers in assessing andimproving the quality of staffing.

The service should consider ways to improve how the residents are involved inchoosing the foundation students who come to support them.






Statement 3We have a professional, trained and motivated workforce which operates to NationalCare Standards, legislation and best practice.

Service strengthsHouse parents worked alongside staff as part of the home's community. This meantstaff were well supported and supervised in their everyday work. In addition daily andweekly meetings meant that all staff had very regular opportunities to discuss theirwork, the people they worked with, and issues or concerns. This meant direction andguidance was always available.

There was a lot of support for staff. As well as meetings, formal and informalsupervision was available regularly. Supervision and support was carried out by theManager and the house parents. For permanent staff there was also an annualappraisal where staff were encouraged to consider the past year, how they hadprogressed and set targets or identify training. We were told the service encouragedstaff to reflect on their practice and how their contribution supported the needs ofthe resident group.

We saw that all new staff were required to undertake induction training. This includedmandatory training. Refresher training was available for the staff when needed. TheManager told us that time was taken to ensure new staff understood theenvironment they were working in, and their responsibilities to the residents whosehome they shared.

Staff told us the work ethos in the home was both demanding and rewarding.However they said they enjoyed the work and that the morale was very good. Noteveryone was able to commit to this way of working and sometimes new staffstruggled. The Manager told us any concerns were raised directly with staff who werefinding the work difficult. In a very few cases they would be supported to leave if thiswas the best option. New staff were monitored closely in the home for the first fewmonths.

Staff we met said they enjoyed the work and the life of the home. They thought therewere very good training opportunities on offer. These included specific training tomeet the needs of the people they worked with, including in epilepsy and workingwith people with difficult behaviours. Staff who were with the service for longer timeperiods were encouraged to take part in more advanced training.

Staff were registered with the Scottish Social Services Council (SSSC) as required. Theywere supported to undertake Scottish Vocational Qualifications or an equivalent.

The Manager told us that senior staff had gained appropriate qualifications for theirwork role.



Areas for improvementThe service should continue to develop training opportunities to ensure that it meetsthe needs of the residents and staff living in The Hollies. In particular it should payattention to providing training that staff may require where people have specificneeds, such as in autistic spectrum conditions.

The notes taken at team and other meetings could be developed to provide a cleareraccount of the discussion that had taken place. Actions that required a change in careplans or risk assessments should be documented clearly.






Quality Theme 4: Quality of Management and LeadershipGrade awarded for this theme: 5 - Very Good

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the management and leadership of the service.

Service strengthsThe comments made in statement 1.1 also apply here.

The residents we spoke with said they thought they were fully involved in the runningof the service. They knew the Manager well and were able to have discussions withthem about the service they received.

The parents we spoke with praised the organisation as well as the service provided atThe Hollies. They thought that their views were listened to and respected. They saidthe service involved them in how the care and support was provided and how planswere made for the future.

One resident in The Hollies was active on the Council, the decision-making body ofTiphereth. Parents said they took part in the regular meetings that both kept theminformed about the service and any changes that were proposed.

A number of meetings and gatherings took place throughout the year. Recently the21st birthday celebration of Tiphereth had taken place. These events provided a rangeof opportunities for parents and carers to meet staff, celebrate the achievements oftheir children, meet the Directors of the organisation and comment on the service.

A number of parents volunteer in Tiphereth services. They said they really enjoyed thework. This helps them keep in touch with the day-to-day running of the service andwhat it is like to be part of it.

Areas for improvementThe service should continue to involve residents and family/carers in assessing andimproving the quality of management and leadership. The views of parents could bemore clearly documented in meeting notes.








Statement 4We use quality assurance systems and processes which involve service users, carers,staff and stakeholders to assess the quality of service we provide

Service strengthsThe strengths found in statements 1.1, 2.1, 3.1 and 4.1 also apply here.

At the last inspection we saw that an external quality audit of the organisation hadstarted. This was called 'Ways to Quality' and was used by all Tiphereth services. Sincethe last inspection more staff had been trained to use the audit tool and the 'Ways toQuality Taskforce' met every two weeks.

We saw that the next stage of the audit had now been completed. This involved thestaff in all parts of Tiphereth. We saw that residential services staff had madecommitments to each other and to the foundation students who worked there. Thiswas to promote greater support and understanding. We look forward to seeing howthis is implemented.

The audit is ongoing and the next stage takes place later in 2014. The focus of this isfor people who use the services. This will contribute to the overall evaluation ofTiphereth

When something goes wrong in a service, for example, if a service user has anaccident, the Manager has to tell the Care Inspectorate. This is called a notification.The Manager was aware of their responsibility to make notifications to the CareInspectorate.

The service should also keep a record of accidents and incidents. An incident is aserious unplanned event that could cause harm or loss. We saw the service hadrecorded a number of incidents and how it had dealt with them. The Manager told uswhat actions they had taken to try to ensure a similar incident would not happen inthe future. We saw the Manager had prepared a report to evaluate the accidents thathad occurred in past years. There had been few and had been managed well.

The service had a complaints procedure and was completing an easy to understandpictorial version. The procedure was up to date and informed people they couldcomplaint to the Care Inspectorate. Everyone told us they knew how to complain buthad no reason to do so. No complaints had been received by the service.

We found the service had a number of systems in place to help it assess the workbeing done. These included:

* staff support and supervision meetings* annual review for permanent staff



* daily/ weekly staff planning meetings* discussions about the progress of each person using the service* daily/ weekly/ monthly systems checks.

We saw that, as well as positive comments from parents, the service had receivedsimilar feedback from other stakeholders.

The Care Inspectorate fully supports the principles of the Learning Disability nationalstrategy - Keys to Life (Scottish Government, 2013). The success of the Camphillcommunities work towards independent and supported living was recognised in thereport. Tiphereth is taking part in an evaluation of their work with EdinburghUniversity, to 'identify outcome measures for individual residents and to implementand evaluate these' (recommendation 30). We look forward to seeing how this hasdeveloped in 2015/6.

Areas for improvementThis small service achieves very positive outcomes for its residents. Its approach iscommunity based and its strengths lie in how everyone who is part of it supportseach other, rather like an extended family. This seems to work very well due to thecommitment of all concerned. The service should continue to demonstrate that itaudits its daily work as well as how it develops quality in the whole organisation.

The service told us they were planning to standardise paperwork across theresidential services in Tiphereth. We will see what progress has been made at thenext inspection.

Grade awarded for this statement: 5 - Very Good





4 Other information

ComplaintsNo complaints have been upheld, or partially upheld, since the last inspection.

EnforcementsWe have taken no enforcement action against this care service since the lastinspection.

Additional Information

Action PlanFailure to submit an appropriate action plan within the required timescale, includingany agreed extension, where requirements and recommendations have been made,will result in the Care Inspectorate re-grading a Quality Statement within the Qualityof Management and Leadership Theme (or for childminders, Quality of StaffingTheme) as unsatisfactory (1). This will result in the Quality Theme being re-graded asunsatisfactory (1).



5 Summary of grades

Quality of Care and Support - 6 - Excellent

Statement 1 6 - Excellent


Quality of Environment - 5 - Very Good


Statement 2 5 - Very Good

Quality of Staffing - 6 - Excellent



Quality of Management and Leadership - 5 - Very Good


Statement 4 5 - Very Good

6 Inspection and grading history

Date Type Gradings

23 Aug 2013 Unannounced Care and support 6 - ExcellentEnvironment 5 - Very GoodStaffing 6 - ExcellentManagement and Leadership 5 - Very Good

17 Jul 2012 Unannounced Care and support 6 - ExcellentEnvironment 5 - Very GoodStaffing 6 - ExcellentManagement and Leadership 5 - Very Good

8 Dec 2010 Unannounced Care and support 6 - ExcellentEnvironment Not AssessedStaffing Not AssessedManagement and Leadership Not Assessed



28 May 2010 Announced Care and support 6 - ExcellentEnvironment 6 - ExcellentStaffing Not AssessedManagement and Leadership Not Assessed

3 Mar 2010 Unannounced Care and support 6 - ExcellentEnvironment Not AssessedStaffing 6 - ExcellentManagement and Leadership Not Assessed

13 Nov 2009 Announced Care and support 6 - ExcellentEnvironment Not AssessedStaffing 5 - Very GoodManagement and Leadership Not Assessed

26 Mar 2009 Unannounced Care and support 6 - ExcellentEnvironment 5 - Very GoodStaffing 6 - ExcellentManagement and Leadership 6 - Excellent

20 Jan 2009 Announced Care and support 6 - ExcellentEnvironment 5 - Very GoodStaffing 6 - ExcellentManagement and Leadership 6 - Excellent

All inspections and grades before 1 April 2011 are those reported by the formerregulator of care services, the Care Commission.



To find out more about our inspections and inspection reportsRead our leaflet 'How we inspect'. You can download it from our website or ask us tosend you a copy by telephoning us on 0845 600 9527.

This inspection report is published by the Care Inspectorate. You can get more copiesof this report and others by downloading it from our website:www.careinspectorate.com or by telephoning 0845 600 9527.

Translations and alternative formatsThis inspection report is available in other languages and formats on request.

Telephone: 0845 600 9527Email: [email protected]: www.careinspectorate.com



Documents

The Hollies Care Home Service Adults