Inspection on 10/05/05 for Holbrook Hall

This inspection was carried out on 10th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holbrook Hall 05/06/07

Holbrook Hall 08/11/05

Holbrook Hall 01/11/04

Holbrook Hall 04/06/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holbrook Hall Makeney Road Holbrook Belper, Derbyshire DE56 0TF Lead Inspector Gail Meads Unannounced 10 May 2005 09:00 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 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 Older People. 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. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holbrook Hall Address Makeney Road, Holbrook, Belper, Derbyshire, DE56 0TF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) (01332) 880698 (01332) 880698 Fairway Homes (Derby) Limited Mrs Barbara Mee Care Home with personal care provided 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 1st November 2004 Brief Description of the Service: Holbrook Hall is a large detached stone building set in its own extensive landscaped gardens. Holbrook Hall is situated in a rural setting with a small village approximately a mile away, which offers basic shopping facilities. The facilities provided are: single rooms mainly with en-suite facility accommodation for 26 older people. Service provided is: 24 hour staff care, 3 meals per day, lighting and heating, other services provided were personal laundry, hairdressing, chiropody and a range of social activities. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors over 4 and a half hours. A full tour of the building took place. Care files and associated records, and medication were looked at. Time was spent talking with 15 out of the 25 service users, and 4 members of staff on duty, as well as the Registered Manager and Registered Provider. What the service does well: What has improved since the last inspection? The Home has a rolling plan of improvements to the general maintenance of the premises. This year all the lounge furniture had been re-upholstered. The Provider strives to improve the Homes policies, procedures, record keeping and health and safety issues. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 6 What they could do better: 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. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4 and 5 Service user needs had been assessed on admission to the home, and the information updated as required. Staff were able to meet the assessed needs of Service users. Trial periods of residency were offered to Service users prior to being offered a permanent place. EVIDENCE: Whilst the needs assessments had been completed, there were areas that lacked detail and in some instances areas of the needs assessment had not been completed. Although risk assessments were completed, staff had not recorded the action that needed to be taken when a risk was identified. Of the 2 Service users used for the purpose of case tracking one had been involved in the assessment process, the assessment documentation found on their file had been signed by the Service user, the information examined did not support that the other Service user had been involved. The information supplied in the assessment and care planning process did not always fully indicate the level of disability that the service user experienced. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 The quality of information provided in care plans was inconsistent. Service users health care needs were assessed and planned for. The policies and procedures carried out by staff around administration and storage of medication did not fully protect service users. Service users felt that they were treated with respect and their right to privacy was upheld. EVIDENCE: The evidence suggested that Service user participation in their Care plans and reviews was inconsistent. Service user Care plans used for the purpose of case tracking indicated that one had a detailed Care plan available; the other Service user’s Care plan was incomplete. Service users had good access to health care professionals and an up to date record of health visits was in place for each Service user Since the last inspection, a dedicated medication refrigerator had been purchased. A maximum and minimum thermometer was available, although staff did not fully understand how to use this. Staff had received training for the Administration of Medication from the local pharmacist. The practice of using medication prescribed to named individuals for communal use was observed. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 10 The actual dose of the medication was not always recorded, for example ‘paracetamol x 2’. Errors were noted on hand written entries, for example ‘Ferrograd Folic’ written as ‘Ferrograd Fol’. Systems did not appear to be in place for checking the accuracy of hand written entries. The dose of several medications had been altered, and the records did not indicate when this had occurred, or who had authorised the change. New entries had not been written when the dose had altered. Prescribed eye drops that were not recorded on the medication records were being administered by staff. A system was not in place to identify the service user with the medication record. The issue of privacy and dignity was addressed throughout the care plans, and Service users spoken to felt their privacy and dignity was respected. The provider and manager said that they had recently organised a wake at the home for a Service user and their family, which included other Service users. The recording of requirements after death was not always consistent. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 15 The social events and leisure activities provided met with service users expectations and preferences. Service users participated in the decision making processes about the day to day running of the home. A varied range of meals and alternative meals were provided, however a small number of Service users were experiencing difficulty with their eating and appropriate equipment had not been supplied to enable Service users to eat the food on their plate more successfully without soiling their clothes.. EVIDENCE: Service users talked of trips every two weeks to garden centres, supermarkets, and into the local area. Service users spoken with had particularly enjoyed the recent trip to a local supermarket; one service user described this, as ‘It was a real treat’. A post box had been provided, which was much appreciated by Service users. Service users spoken with were able to describe the range of regular activities that were organised All the Service users spoken to confirmed that they were able to choose the activities and social events they wished to join in and enjoyed the activities and social events provided. Service users talked about the recent election and that they had voted by post. Service users were able to choose the décor in their rooms. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 12 Regular Service user meetings were held, and Service users were able to participate in the day to day decision making processes within the Home. A wide range of meals were provided. Alternatives meals were available as were special dietary needs, food was well presented and hot, tureens were taken to each table to enable Service users to help themselves. There were issues about the provision of appropriate equipment being provided i.e. plate guards to enable the less able Service users to maintain their dignity whilst eating. staff input during meal times is minimalised to enable the promotion of service users’ independence. The atmosphere during the meal period was calm, relaxed and sociable. Service users were very complementary about the food provided. There were no complaints expressed by Service users. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Service users were well aware of the complaints procedure and how to complain. EVIDENCE: Service users spoken with said that they had no complaints, but they were aware of how to complain and who to. One Service user said ”if I was not happy they would soon know about don’t you worry”. One service users whose care was case tracked produced a copy of the Service User Guide and found the complaints procedure within it. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 26 The environment was both safe and comfortable, and maintained internally and externally to a good standard. EVIDENCE: Ongoing investment in the fixtures and fittings was evident. All the furniture in communal areas had been reupholstered. Bedrooms were redecorated and refurbished on a rolling programme. Toilets and bathrooms met the assessed needs of Service users. Aids and adaptations suitable for the current Service user group were provided. Service users spoke about being able to bring in their own possessions. All areas of the home were found to be warm, airy, clean and well ventilated Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staffing hours were sufficient to meet the needs of service users. EVIDENCE: Staffing levels remain above the minimum staffing levels required. Duty rotas were clear and concise, detailing who was on duty at what time. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 The Registered Manager and Provider were experienced, qualified, competent and caring The Registered Manager provided clear leadership and had good management skills. EVIDENCE: Staff spoken with confirmed a high level of confidence in the management group. Service users spoke very highly about all of the staff team, and the Providers. Both the Registered Manager and Provider had achieved NVQ Level 4. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x x x Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) and (c) 4(c) Requirement The registered provider must ensure that a fully completed assessment of needs is in place for each Service user. The registered Provider must ensure that risk assessments are completed for each Service user and that appropriate action is taken to eliminate the risk. The registered Provider must ensure that medication is administered and recorded as identified in the Homes Administration of Medication policy The registered Provider must ensure that Sercice user Care plans are fully completed Service users must be involved (where appropriate) in the development of their Care plan. Timescale for action 01/07/05 2. OP3 01/07/05 3. OP9 13(2) 30/05/05 4. 5. OP7 OP7 15(1) 15(1) 30/05/05 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 19 Holbrook Hall 1. 2. OP9 OP15 A photograph of each Service user should be attached to their own M.A.R sheet to enable safe administration of medication The registered Provider should provide appropriate equipment i.e. plate guards to enable Service users to eat their meals without soiling their clothes. Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holbrook Hall C52 C02 S20017 Holbrook Hall V226694 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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