CARE HOMES FOR OLDER PEOPLE
Holbrook Hall Makeney Road Holbrook Belper Derbyshire DE56 0TF Lead Inspector
Gail Meads Unannounced Inspection 8th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000020017.V264253.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Holbrook Hall Address Makeney Road Holbrook Belper Derbyshire DE56 0TF (01332) 880698 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) Fairway Homes (Derby) Limited Mrs Barbara Mee Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th May 2005 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 DS0000020017.V264253.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a two and a half hour period. Additional time was spent in preparation for the visit, looking at previous reports and other documents. During the inspection process a number of documents were examined, including residents’ care files, staff files and records, time was spent looking around the building and speaking to a number of residents, and to the manager and staff. The inspector spent a specific amount of the inspection concentrating on the care arrangements for the two residents for the purpose of case tracking. What the service does well: What has improved since the last inspection?
Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 6 There is limited room for improvement as the provider and staff have worked hard to carry out any requirements made in the last inspection report. Anew extractor fan has been fitted to the oven and the loft has been completely re insulated. The home continues to have a rolling programme of maintenance in place. 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 DS0000020017.V264253.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 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 the following standard(s): 1.3. The needs assessments are now being completed more fully. EVIDENCE: The home provides a comprehensive Statement of Propose which was examined and found to be satisfactory. Two of the most recent residents’ files were examined and there were completed needs assessments in place. The assessments were detailed and comprehensive. Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 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 the following standard(s): This Standard was not assessed during this inspection. All the Standards met requirements in the last inspection dated 10/05/05. EVIDENCE: Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 13. The home prides itself on the range of social and leisure activities provided. EVIDENCE: The home offers a wide range of activities which includes crafts exercise to music, reminiscent groups, fortnightly trip out, board games, a pianists visits weekly and there visitors from the different local churches. Residents can go to the theatre if able. The residents have regular visitors and they are encouraged to join in any social events or activities taking place. Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 17.18. Residents would be supported if they needed legal assistance. The home has robust systems in place to deal with issues of abuse of residents if they were to occur. EVIDENCE: There are advocacy services displayed to enable residents/relatives the opportunity of an independent service if required. The manager stated that a solicitor would be found for any resident who needed this service. All the residents retain their right to vote. The home has a full and detailed Adult Protection policy, which is in line with Derbyshire County Councils policy. All staff have received appropriate adult protection training. Staff are aware of the importance of identifying any kind of abuse of residents and know the procedure for reporting any concerns they may have. Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 12 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 the following standard(s): This Standard was not assessed during this inspection. All the Standards met requirements in the last inspection dated 10/05/05. EVIDENCE: Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28.29.30. The home has a well trained and competent staff group. The homes recruitment process is adhered to. EVIDENCE: Two staff files were examined and found to be well organised and contained the required documentation as identified in Schedule 2. There was a clear recruitment process with completed applications and interviews. A Quality Assurance system is in place and written feedback is given to residents/relatives as required. Two references are had been taken up prior to the commencement of their employment, as had all the relevant police and medical checks required. All staff have now achieved NVQ level 2 and above, the home now has trained NVQ assessors within the staff group. Staff have received the mandatory and induction training required and a wide range of relevant training. The staff training opportunities are excellent. Staff spoken to confirmed that they had very good training opportunities. Residents spoken to spoke highly of the level of care received from staff. Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32.33.34.35.36.37.38. The home has structures and systems in place to enable the health and safety of residents at all times. EVIDENCE: There are regular staff and residents meetings held minutes from these meetings were examined and cover a good range of issues that are relevant to the daily running of the home and the development of its policies. Residents spoken to said they could always talk to staff and the provider they expressed no concerns and said they were given enough information. The provider has accounting information available for inspection, which indicated there were no financial issues at the time of the inspection. Residents’ financial transaction are all recorded and receipted with two signatures given. A small number of required records were examined and found to be satisfactory these included care plans, staff files and documentation,
Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 15 complaints, residents financial transaction records and the Statement of Purpose. The home has a current insurance policy displayed in the front entrance; all the required services of hoists, fire equipment, gas and electricity had taken place. The Environmental Health and Fire officer reports were satisfactory. Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 16 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 3 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 4 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 3 x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 3 3 3 3 3 Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Holbrook Hall DS0000020017.V264253.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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