Inspection on 12/05/05 for Holderness House

This inspection was carried out on 12th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holderness House 02/12/08

Holderness House 07/02/07

Holderness House 01/11/05

Holderness House 26/10/04

Holderness House 17/06/04

Holderness House 18/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holderness House 373 Holderness Road Kingston upon Hull East Yorkshire HU8 8QX Lead Inspector Simon Morley Unannounced 12 May 2005 at 9:15 am th 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. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holderness House Address 373 Holderness Road Kingston upon Hull East Yorkshire HU8 8QX 01482 702657 01482 703770 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) Holderness House Trust Mrs Wendy Jones Care Home 33 Category(ies) of OP - Old Age (33) registration, with number of places Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 26th October 2004 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 J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted for 8 hours and no additional visits have been made to the home since it’s last inspection in late October 2004. The inspector looked at records about the care of residents spoke to 6 of the residents, 1 visitor, 2 care staff and the manager. What the service does well: What has improved since the last inspection? The manager has made some progress in ensuring that everyone receives an assessment of what they need before they move into the home. Further work needs to be done to make sure this happens for everybody. Some work was undertaken to modernise the central heating system. Following this the manager plans to ensure that all radiators are made safe to protect residents from the risks of radiators with hot surfaces. The home has produced it’s first newsletter ‘The Holderness Herald.’ This included information about the history of Holderness House, recent improvements and changes to the home to help keep residents up to date, and topical information. This was popular with the residents, some of whom said they were going to write their own piece for the next edition. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 6 New dining chairs –‘carvers’– have been bought, the arms on the chairs support residents to get up after their meal. 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 J54_s853_Holderness House_v226665_120505_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 Holderness House J54_s853_Holderness House_v226665_120505_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) 3. Further progress is needed to improve the admission procedure to ensure 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 that had been written down as a plan of care based on each resident’s assessment. Individual care records are kept for each resident. An inspection of the records for 3 residents recently admitted showed that not all care records had been completed. There was no assessment for one resident. This puts her at risk from receiving a poorer quality of care as staff may not know what all her needs are. This was also noted at the last inspection when a requirement was made for action to be taken to ensure that all residents have their care needs assessed before moving into the home. That requirement referred to assessing people paying for their care or coming to the home for ‘respite care’ in both cases a minority number. Action was taken by the manager about this. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 9 The resident recently admitted without an assessment had moved into the home on a long-term basis and the lack of assessment was an error in the home’s admission process. It is not usually the norm for the manager not to assess some one moving into the home on a permanent basis. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10. Not all residents had their care needs set out in an individual plan of care and as a result are potentially being put at risk. On a positive note staff are polite, friendly and residents felt they were treated with the respect they deserve. EVIDENCE: Individual plans of care are part of the care records for each resident. Of the 3 sets of records looked at, one resident did not have an individual plan of care. Staff spoken to had some awareness of peoples’ individual needs. But without a clearly recorded plan of care detailing all a person’s care needs, the care given will rely on the memory of, and good communication between staff. So, any resident without a care plan is more at risk of not having all their care needs met. Despite this 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. All the residents spoken to were full of praise for the attitude of staff and how staff spoke to them and supported them with their care. This was seen in the behaviour and manner of staff when interacting with the residents. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 11 Residents are called by their preferred name, have access to a private telephone or can have a telephone in their rooms. Staff knock on bedrooms doors, provide personal care in a dignified manner and have a genuine respect for each resident as an individual human being. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 12 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, 13, 14 and 15. The range of activities did not suit all the residents and improvements are needed to ensure all residents benefit from more social stimulation. Visiting arrangements are good. Residents are supported to make choices to help keep their independence. There was a balanced menu for residents to choose from which ensures a wholesome and nutritious diet is on offer. EVIDENCE: The home’s activities list was on display but there were no planned activities on the day of inspection. Activities usually take place in the lounge. Residents sat in the lounge in the afternoon (of the inspection) received little in the way of social stimulation. Two of these residents complained of boredom but did say they liked joining in with activities when they were arranged. Providing activities to suit everyone’s taste is hard for the home especially as the more independent residents chose not to mix with those who are less able and confused. It is the less able who use the lounge frequently. Residents could choose the privacy of their own rooms in which to spend their time and those who were independent enough went out. This was seen by the inspector on the day. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 13 Residents and visitors said that they liked the visiting arrangements and special arrangements could be made e.g. one resident was being visited by her son and a table was laid in the library for them to lunch together in private. Staff were observed to also offer residents choice e.g. what music to play in the lounge, whether to turn the heating up/down. The inspector ate lunch with the residents who could choose what top eat from the homes menu. There was a choice of two different main courses each day or residents could have a light soup instead. The dining room had a pleasant atmosphere with attractively laid tables. Staff served the choice of meal to each resident. Vegetables of the day (grown in the home’s garden) were served on platters for residents to help themselves. Residents said they could also eat in their rooms but are encouraged to make meals a sociable event. Residents weight was regularly monitored and nutritional supplements were obtained for residents that needed them. A new set of dining chairs had recently been purchased, all chairs were ‘carvers’ and the arms on the chairs help residents to get up. A range of adapted cutlery and crockery was used by residents who needed it to eat independently. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 14 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) None of the outcomes for these standards were assessed on this occasion. EVIDENCE: Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 15 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) None of the outcomes for these standards were assessed on this occasion. EVIDENCE: Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 16 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) 29. The protection of the residents was not supported by the home’s recruitment practices. EVIDENCE: The manager reported that one member of staff had been recruited to work in the home since the last inspection. She also admitted that she had not undertaken all the required recruitment checks to ensure the protection of residents. More specifically, a Criminal Records Bureau check and a check of the list of people banned from working with vulnerable adults were not completed. This was also noted at the last inspection when a requirement was made for action to be taken to ensure that these recruitment checks were made before appointing staff to work in the home. A letter was left for the manager and owners stating that this must be put right immediately or further enforcement action would be taken against the home. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 17 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) None of the outcomes for these standards were assessed on this occasion. EVIDENCE: Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 19 Yes 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 3 Regulation 14 Requirement The registered person must not provide accomodation to any resident unless the needs of the resident have been assessed by a suitably qualified or trained person covering the areas listed in National MInimum Standard 3 for Care Homes for Older People. All residents must have an individual plan of care based on the assessment of their needs. Residents must be given more opportunities for leisure and social stimualtion which suit needs. Particlaur consideration must be given to people with dementia, sensory impairment and physical disabiltiies. Pipe work and radiators must be guarded or have guaranteed low surface temperatures. (Original timescale of 31st May 2004 not met). A satisfactory CRB disclosure and a check of the POVA list must be obtained prior to staff working in the home. (Original timescale of the next staff appointment not met.) Timescale for action 31st July 2005. 2. 3. 7 12 15 12 and 14 31st July 2005. 31st July 2005. 4. 25 13 31st August 2005. 5. 29 19 Immediate. Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 20 6. 30 18 The registered person must ensure that there is an induction training programmes that meet the Skills for Care targets. (Original timescale of 31st May 2004 not met.) 31st August 2005. 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 NA Good Practice Recommendations NA Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 © 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 Holderness House J54_s853_Holderness House_v226665_120505_Stage 4.doc Version 1.30 Page 22 - 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. 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