CARE HOMES FOR OLDER PEOPLE
Holderness House 373 Holderness Road Hull East Yorkshire HU8 8QX Lead Inspector
Simon Morley Unannounced Inspection 1st November 2005 09:00 X10015.doc Version 1.40 Page 1 X10015.doc Version 1.40 Page 2 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 Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 3 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. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Name of service Holderness House Address 373 Holderness Road Hull East Yorkshire HU8 8QX 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) 01482 702657 holderness.house@virgin.net Holderness House Trust Mrs Wendy Jones Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 5 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th May 2005 Brief Description of the Service: Holderness House is a care home registered to provide personal care and accommodation for up to 33 people over the age of 65. The home is run by Holderness House Trust, a charitable trust set up by a local Victorian industrialist and philanthropist. Holderness House is a large 19th Century mansion house set in extensive grounds on Holderness Road, about two miles from the centre of the city of Kingston upon Hull. The original building is believed to be a Grade II listed building. There is also a purpose-built extension. The home is set in the heart of a bustling community: There is a wide range of shops, churches, clubs and pubs close by. There is a bus stop very close to the home. The home provides accommodation in single rooms (some very large) on three floors. Almost all have ensuite WC and wash hand basin facilities, whilst a few also have a shower or bath. There is a very pleasant louge, a large dining room and a library, which can also be used as a quiet room where meetings can be held. There is a passenger lift with access to all three floors. There are very pleasant, large and well-kept gardens to which adaptations have been made to allow access for wheelchair users. There is also ample parking space for visitors Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection lasted for 7 hours and included looking at records about the care of residents speaking to four of the residents, two care staff, the deputy and the manager. What the service does well: What has improved since the last inspection?
The admissions process had improved, this time all residents had had their needs assessed and had a written care plan based on this. New staff had been recruited properly and the required checks made before they started work to protect residents from people who should not work there. There were better arrangements for providing social stimulation for residents to help keep their minds and bodies fit and active. Work is ongoing to modernise the central heating system. More radiators have been made safe to protect residents from the risks of radiators with hot surfaces. The manager plans to make the remaining radiators safe. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 7 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. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 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 Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The admission procedure is good and ensures that all people have their needs assessed before moving into the home. This is necessary to ensure that all the care needs of all of the residents can be met. EVIDENCE: Residents spoken to were happy that their care needs were being met. Staff spoken to were aware of individual resident’s needs and were aware when these needs had changed. Individual care records are kept for each resident. An inspection of the records for three residents recently admitted showed that all of them had had their needs assessed prior to admission. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 10 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): 7 and 8 The arrangements for ensuring residents health and personal care needs were met were good. EVIDENCE: Residents spoken to were happy with their care. They also said that they got enough support from staff to make sure their health care needs were met. Staff spoken to were aware of people individual needs, had access to their written care plans and knew when somebody’s needs had changed and acted accordingly. Individual plans of care are part of the care records for each resident. Of the three sets of records looked at all included a care plan. There were detailed records of the health care of each resident. The detail and quality of care plans could improve (e.g. more detail of the care to be provided, when, by whom and how it would be monitored) and the manager had plans to do this. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 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 the following standard(s): All of these outcomes were assessed at the last inspection. EVIDENCE: Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 12 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): 16 and 18 There were good arrangements to make sure that people’s complaints were listened to and they were protected from abuse. EVIDENCE: Residents spoken to had no complaints. One resident did complain to the manager about something that happened during the inspection, this was resolved to her satisfaction. Records are kept of complaints and what has been done to resolve them, if people are still unhappy they can take their complaint to the ‘Ladies Committee’. This committee reports to the Board of Trustees. The manager and staff spoken to were aware of what was poor and abusive practice. All were adamant that they would report any thing of this type to keep residents safe. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 13 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): 19 and 26 Holderness House is a grand building set in extensive gardens. It is well kept, clean, comfortable and smells fresh. EVIDENCE: The home is accessible, set in the heart of a bustling community but set back in its large grounds. There is wheelchair access, which the manager plans to improve. The home is clean and smells fresh, there are no malodours. Furniture is comfortable and homely. Residents were pleased with the home and it’s surroundings. The home is well maintained and maintenance certificates were available. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 14 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): 27, 28, 29 and 30 The arrangements for ensuring the home was adequately staffed were good. EVIDENCE: Using the manager’s figures for the number of residents with ‘high, medium or low’ needs the recommended staffing guidance calculates there should be just over 550 care hours per week. The staff rota provides 490 care hours per week. The manager was advised to get a copy of the guidance and make sure her figures were correct. The home is not currently required to meet this guidance unless it became clear there were not enough staff to care for the residents properly. This was not the case. The home also employs a range of ancillary staff to help in the smooth running of the home. The home has met the target for 50 of the care staff to achieve the NVQ Level 2 qualification. New staff had been appointed since the last inspection. Inspection of their recruitment records showed that all the required checks were made before they started work. This is to make sure they were suitable for the job and not put residents at risk from harm. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 15 Staff undertake a range of training and there were individual staff records of the training each person had done and what they needed. There were some copies of training certificates as well but a large number of these were missing. It was discussed with the manager that she must keep copies of staff training certificates on file as well. It would also be of benefit if the individual training records were used to develop a formal training plan for the year. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 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 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): 31, 33, 35 and 38. There is good management and administration of the home. EVIDENCE: The current manager is experienced and qualified, she also undertakes regular training to keep up to date with good practice. Residents are able to make their views known about the service in several ways. The manager is approachable, - on the day of inspection a resident did complain verbally to her and the issue was resolved at the time, – there are regular residents meetings, and residents are also given satisfaction surveys to complete. The home only looks after some of the residents’ finances and there were accurate and up to date records kept. Residents spoken to were all happy that
Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 17 they received their full personal allowance or were happy for their relatives to look after their money. The home was physically safe and well maintained and maintenance certificates were available for inspection. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 18 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 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 19 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. 1 Standard OP30 Regulation 18 Requirement Copies of staff training certificates must be kept in the home. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP27 OP27 OP30 Good Practice Recommendations The detail and quality of care plans should improve (e.g. more detail of the care to be provided, when, by whom and how it would be monitored). The manager should obtain a copy of the recommended staffing guidance and use it to calculate what the home’s care staffing hours should be. The care staffing levels should be increased to meet the recommended guidance. Staff training records should be used to develop a formal training plan for the year. Holderness House DS0000000853.V263658.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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