Inspection on 11/06/09 for Hollybank Nursing Home

This is the latest available inspection report for this service, carried out on 11th June 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hollybank Nursing Home 08/08/06

Hollybank Nursing Home 08/02/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Hollybank Nursing Home 30-32 Skinner Street Creswell Nr Worksop Nottinghamshire S80 4JH Lead Inspector Rose Moffatt Key Unannounced Inspection 11th June 2009 09:30 DS0000066973.V375935.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank Nursing Home Address 30-32 Skinner Street Creswell Nr Worksop Nottinghamshire S80 4JH 01909 721247 F/P 01909 721247 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) Hollybank Nursing Home Limited Mrs M A Dibb Mrs M A Dibb Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2008 Brief Description of the Service: Hollybank Nursing Home is situated in the village of Creswell, near to Worksop, within easy reach of the MI motorway. The home provides personal and nursing care for up to 30 older people. The home comprises two Edwardian period houses joined by a new building link. Accommodation is on two floors in 22 single bedrooms, (12 with en-suite toilets), and 4 shared bedrooms. There is a choice of lounge and dining areas in the home. The first floor is accessed by stairs or a passenger lift. There is a large accessible garden. The fees range from £333.85 to £498.30 per week, depending on assessed needs. The fees include hairdressing and newspapers. This information was provided by the manager on 11th June 2009. Information about the home, including CSCI/CQC inspection reports, is available from the manager. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use the service experience adequate quality outcomes. The focus of our inspection is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the providers ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information we have received, or asked for, since the last key inspection or annual service review. This included: • the annual quality assurance assessment (AQAA). The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also has some numerical information about the service • surveys returned to us by people using the service and from other people with an interest in the service • information we have about how the service has managed any complaints • what the service has told us about things that have happened - these are called notifications and are a legal requirement • the previous key inspection and the results of any other visits we have made to the service in the last 12 months • relevant information from other organisations • and what other people have told us about the service. We carried out an unannounced inspection visit that took place on 11th and 12th June 2009, (7 hours in total). The inspection visit focused on assessing compliance with requirements made at the previous inspection and assessing all the key standards. There were 26 people accommodated in the home at the time of the inspection visit. People who live in the home, visitors and staff were spoken with during the visit. The owner/manager was available for most of the inspection visit. Some people were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Case tracking was used during the inspection visit to look at the quality of care received by people living in the home. 3 people were selected and the quality of the care they received was assessed by speaking to them and / or their relatives, observation, reading their records, and talking to staff. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 6 The inspector was accompanied by an expert by experience, Jan Colombo, for part of the inspection visit. An expert by experience is a person who, because of their shared experience of using services, and / or ways of communicating, visits a service with an inspector to help get a picture of what it is like to live in or use the service. The expert by experience spoke to people living in the home, their relatives, and staff about the lifestyle in the home and their views of the service. Information from the findings of the expert by experience has been included in the body of this report. What the service does well: People told us they were happy at the home and their needs were met. They said, “Living here is excellent. I have no complaints. In fact, I wish I had come here years ago.”, “I am looked after well”, “It is lovely. They take good care of me”, and, “You do not have to ask twice for anything. Nothing is too much trouble”. The expert by experience commented, “I found the care staff had very caring attitudes and treated service users with dignity and respect. All communication that I heard was appropriate. The residents I spoke to seemed happy and well cared for”. People told us the home was “homely”. They said, “My room is lovely, always warm and spotlessly clean”, “I have a lovely room, with my own pillows, TV, radio, etc. It is very clean”, and, “My room is lovely with my own things in it”. There was a good training programme for staff at the home. Most of the care staff had achieved a relevant National Vocational Qualification (NVQ) at level 2 or above. What has improved since the last inspection? What they could do better: We had not received notifications of incidents in the home as required. This is necessary to ensure people in the home are fully protected. There should be a formal system in place to ensure the proper supervision of staff. This would help to ensure the needs of people in the home are fully met, and to ensure that staff are well supported to meet those needs. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 7 None of the recommendations made in the last report were carried out. The recommendations relate to the National Minimum Standards and are seen as good practice for the provider to consider. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a satisfactory assessment process so people were confident their needs could be met at the home EVIDENCE: People told us their needs were met at the home. They said, “Living here is excellent. I have no complaints. In fact, I wish I had come here years ago” and, “I’m very settled here. It feels like home”. We looked at the records of 3 people in the home and found they all had appropriate assessments by social services staff and/or nurses. The assessments covered all areas of need and had been obtained prior to the admission of the person. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 10 Suitable equipment was provided to meet people’s needs, such as height adjustable beds, pressure relief mattresses and cushions, wheelchairs and lifting hoists. One person who needed hoisting in and out of bed was not in a height adjustable bed which would make manual handling easier and safer. The AQAA said that day visits were encouraged before the person made the choice about coming into the home, and that the home was flexible to accommodate most people’s preferences. The AQAA said the home could improve by having better information for people thinking of coming to live in the home. Standard 6 did not apply as there were no people receiving intermediate care at the home. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were generally satisfied with the care provided, some improvements had been made to care plans, and medication was well managed. However, there was an inconsistent approach to care planning and review, and people were not actively involved to ensure their needs and preferences were fully met. EVIDENCE: People told us, “I am looked after well”, “It is lovely. They take good care of me”, and, “You do not have to ask twice for anything. Nothing is too much trouble”. The expert by experience commented, “I found the care staff had very caring attitudes and treated service users with dignity and respect. All communication that I heard was appropriate. The residents I spoke to seemed happy and well cared for”. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 12 The care plans we looked at had good details of the action required by staff to meet people’s needs. The care plans included reminders to staff to ensure the person’s dignity and privacy. The care plans had all been reviewed, though not monthly. There was no indication that people, or their representatives, had been involved in care planning. One person did not have a care plan on the first day of the inspection visit, even though they had been in the home for several months, and two people had gaps in their care plans. When we brought this to the manager’s attention, the relevant care plans were put in place by the second day of the inspection visit. One person told the expert by experience that they preferred a shower to a bath but had never been offered a shower. There were assessments of manual handling needs, risk of developing pressure sores, nutritional needs, and risk of falls. Some assessments were not signed or dated. There were records of visits by healthcare professionals, such as GP, optician and occupational therapist. People told us they saw their GP as necessary, they said, “Staff check me regularly. If I am ill, they get a doctor with no delay.” Relatives said they were kept up to date with any health concerns about the person. Daily records were mostly informative, although there were some repetitive entries with no useful information about the person. Staff told us they always had up to date information about the needs of people in the home. They were knowledgeable about the individual needs and preferences of people in the home. We found satisfactory procedures in place and good records of the safe handling and administration of medication. The AQAA said that improvements had been made to the medication records since the last inspection. The AQAA said further improvements in care documentation were planned. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a lack of organised activities so that the social needs and preferences of people were not met. EVIDENCE: People told us “It is a happy atmosphere here.”, “it feels like home”, “I choose to go to bed early and get up early, because I have been used to it all my life”. One person said “the routine is like a hospital”. Most people told us there were few activities provided at the home. They said, “I have played bingo, but not often”, and, “Newspapers are always available and library books”. Staff told us they organised some activities, such as playing games, and one member of staff said, “Caring is not just a physical activity. It is essential that we sit and have a chat with them”. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 14 Routines appeared flexible with people able to get up and go to bed when they wanted to, and able to have breakfast at any time during the morning if they wished. We observed that people could move freely around the home and could choose where to eat their meals. There were no meetings for people in the home and / or their representatives to share their views and ideas for improvements. There was no information available about local advocacy services. Visitors told us they were always made welcome and could visit at any reasonable time. Most people told us they enjoyed the meals at the home. They said, “The food is lovely. There is a choice. You can have more if you want it”. “The food is excellent. They have different cooks, but they are all good. We get good helpings” “The food varies. There is not really a choice. They are trying to suit everyone, so it is not easy. There is always plenty to eat”. The manager said new menus were being created to provide more choice at each meal. People in the home had been asked for ideas for the new menus. There were no menus displayed to let people know what meals were to be provided that day. The AQAA said the home had improved by creating the new menu and could improve further by trying to promote more interest in activities. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were confident their complaints would be listened to and appropriate action taken. However, there were still gaps in reporting that could put people at risk. EVIDENCE: People told us they would go to the manager or staff with any complaints and were confident that appropriate action would be taken. One person told the expert by experience, “If I had a complaint, I would tell the manager. She is always there to listen, as are the other staff. They would look into it for me.” The complaints procedure in the main entrance area of the home had not been updated as recommended at the last inspection and so did not have the correct contact details for the Care Quality Commission. We were aware of one complaint made directly to the manager and saw records of this. The records did not show a chronology of events with the action taken and outcome at each stage. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 16 There were satisfactory policies and procedures in place about safeguarding vulnerable adults. Staff had received appropriate training and were aware of the correct procedures to follow. There was information available about the Mental Capacity Act 2005 and the manager said that staff training was planned. We had received notifications of all deaths in the home since the last inspection. However, we had not been notified of all serious injuries in the home as required. We found that the recording of accidents in the home had improved since the last inspection. The AQAA said they listen to concerns by discussion with all parties concerned and they have staff training to promote awareness. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean, suitably equipped and generally well maintained so that people had a comfortable, homely environment that met their needs and expectations. EVIDENCE: People told us the home was “homely”. They said, “My room is lovely, always warm and spotlessly clean”, “I have a lovely room, with my own pillows, TV, radio, etc. It is very clean”, and, “My room is lovely with my own things in it”. The expert by experience commented “Hollybank is a clean, spacious, pleasant home. Most areas I saw were maintained to a good standard and looked attractive”. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 18 Improvements had been made since the last inspection including new furniture in the lounges, new flooring in the office, and redecoration of some of the bedrooms. Some areas remained in need of redecoration, including where water leaks had caused damage to plaster and decor. A window pane in one bedroom was cracked. The garden was accessible and had suitable furniture for people to use. The expert by experience commented “The garden was surrounded on one side by trees, where a resident told me that they could watch birds. I did not see any bird feeders, which I thought would have been useful to attract more birds”. Smoking was not allowed in the home and so people in the home, visitors and staff smoked in the garden. Although a bin was provided, there were a lot of cigarette ends on the ground on the day of the inspection visit. Since the last inspection, new cleaning regimes had been implemented to ensure better standards of cleanliness. Staff had received advice and training about infection control. The AQAA said the home maintained a clean, comfortable and homely environment. The home planned to improve by ongoing redecoration of the home and further training in infection control. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were supported by a well motivated and competent staff team in sufficient numbers to ensure their needs were met. The home’s recruitment procedure was not fully robust to ensure that people were completely protected. EVIDENCE: People said staff were usually available when needed. People told us, “The staff are nice. They help you.”, and, “Staff do anything you ask.” A relative said, “The staff are brilliant. You could not ask for anything else. They are so good to him. He needs help with everything now. You do not have to ask twice for anything. Nothing is too much trouble.” We looked at the records for 8 members of staff. All had the required documents and information in place, except for proof of their identity. All of these staff had worked at the home for several years. We requested to see the record of a member of staff recruited since the last inspection, but the manager said this record was not available as a key had been mislaid. We were therefore unable to assess the induction programme for new staff. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 20 There was a good training programme at the home, covering all the required training for staff. Staff we spoke with confirmed they had received relevant training that helped them to ensure people’s needs were met. Most of the care staff had achieved a relevant National Vocational Qualification (NVQ) at level 2 or above. There were no formal staff meetings at the home. The manager said staff had the opportunity to raise any matters informally at daily handovers. Staff told us they would like staff meetings to sort out any problems and bring ideas for improvements. There was a low turnover of staff with many staff having worked at the home for several years, and no use of agency staff. Staff told us they liked working at the home as there was a good atmosphere. They said, “It is hard work but enjoyable.”, “I love coming to work”, and, “we all support each other”. The AQAA said the home had a highly motivated team and a good training system. The home had improved by incorporating more variety in staff training. The home planned to improve by encouraging more staff to complete their NVQ, and to improve staff records. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management approach was not pro-active or robust enough to ensure the safety and welfare of people in the home was always fully protected. EVIDENCE: The manager was also the owner of the home and was suitably qualified and experienced. The manager had a ‘hands on’ approach and worked as the nurse in charge, usually for 5 shifts per week. The manager had administrative help for 10 hours per week. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 22 People told us they liked the manager and they were confident she would take appropriate action to sort out any problems. The AQAA was completed by the manager. The information in the selfassessment section was brief and gave few details of how they planned to improve. Several parts of the data section were not completed. Surveys were used to find out people’s views of the service provided. The manager said that the menus had been changed as a result of listening to people’s views. There was no system in place for supervision of staff in the home. Records of the maintenance and testing of fire safety systems and equipment were up to date. There were gaps in care records such as no care plan in place for one person, and two people with missing elements from their care plans. When discussed with the manager, she took action during the inspection to put this right. We were unable to look at the record of a member of staff recruited since the last inspection as the manager told us a key had been mislaid. Although notifications of deaths had been made to CQC as required, notifications of serious injuries to people in the home had not been made. We made a requirement at the last inspection for all deaths, illnesses and other events to be notified to us. Following this inspection, we wrote to the provider asking them to complete an improvement plan and warning them we may take further action. We found that none of the recommendations made in the last report were carried out. The recommendations relate to the National Minimum Standards and are seen as good practice for the provider to consider. Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 2 Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1) Requirement There must be a care plan in place for each person in the home that includes all of their assessed needs. This was a requirement at the previous inspection of 06/08/08 and was partially complied with. The home must be kept in a good state of repair, specifically: • the first floor bathroom ceiling, the area of wall on the staircase, and the porch must be repaired and redecorated where damage has been caused by a water leak • the window pane in the identified bedroom must be replaced This will ensure a well maintained and pleasant environment for people living in the home. 2 OP29 19(1)(b) There must be proof of identity for each person employed at the home. This will help to ensure a DS0000066973.V375935.R01.S.doc Timescale for action 10/07/09 1 OP19 23(2)(b) 30/09/09 31/08/09 Hollybank Nursing Home Version 5.2 Page 25 robust recruitment procedure to protect people living in the home. 3 OP36 18(2)(a) There must be a system in place to ensure appropriate supervision of staff working in the home. This will help to ensure the needs of people in the home are fully met, and that staff are well supported to meet those needs. 4 OP38 37 CSCI must be notified without delay of the occurrence of deaths, illnesses and other events as specified in the regulations. This is to ensure people are protected. This was an Immediate Requirement at the previous inspection of 06/08/08 and was partially complied with. 30/06/09 30/09/09 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 OP7 Good Practice Recommendations Care plans should be reviewed at least every month to ensure that people’s changing needs are monitored and fully met. People living in the home, and/or their representatives, should be more actively involved in the planning and review of care. This will help to ensure that care is provided in the way people expect and prefer. 2 OP7 Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 26 3 OP9 4 OP12 The daily minimum and maximum temperatures of the fridge sued to store medication should be recorded. This will ensure that medicines are stored correctly to avoid any deterioration. The programme of activities should be developed so that all people in the home are offered opportunities to meet their social and leisure needs. There should be information about local advocacy services available in the home for people and their representatives to ensure people have access to independent support and advice. Daily menus should be displayed in a suitable format for people in the home so they know what choice of food is available. The complaints procedure displayed should be updated to include the correct address for CQC. This will ensure that people have the information they need if they want to raise concerns. There should be security measures at the main entrance so that staff are always aware of visitors coming into the home. This will ensure that people in the home are fully protected. There should be more administrative support for the manager. This would benefit people by ensuring better organisation of the home. An annual report of the quality assurance surveys should be made available to people living in the home and their representatives. People will be assured that their views are taken seriously and that the home is run in their best interests. Records of fire drills should include the names of staff / others who took part, any issues arising, and the action taken to address the issues. This will help to ensure people are protected. 5 OP14 6 7 OP15 OP16 8 OP19 9 OP27 10 OP33 11 OP38 Hollybank Nursing Home DS0000066973.V375935.R01.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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