Inspection on 20/07/05 for Holland House

This inspection was carried out on 20th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Holland House 20/08/07

Holland House 22/08/06

Holland House 06/04/06

Holland House 08/09/05

Holland House 16/11/04

Holland House 13/05/04

Holland House 05/01/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

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

CARE HOMES FOR OLDER PEOPLE Holland House 35 Church Street Market Deeping Lincolnshire PE6 8AN Lead Inspector David Bacon Unannounced 20 July 2005 08:30 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. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holland House Address 35 Church Street Market Deeping Lincolnshire PE6 8AN 01778 345677 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) Mr A Kachra Care Home 21 Category(ies) of DE Dementia Both 1 registration, with number OP Old Age Both 20 of places Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 November 2004 Brief Description of the Service: Holland House is registered to accommodate 21 service users, and is situated in the centre of Market Deeping. It is a large detached stone built property, and is a Grade 2 listed building. The main part of the building accommodates 15 service users. The home formally provided accommodation for 6 service users in the former barn, but this is now not in use, although the Commission had not received a request to vary the registration at the time of the inspection. Accommodation is arranged on two floors, with the third floor being used as a staff sleep-in room, and offices for Country Care Homes. Ground floor accommodation comprises a sitting room, dining room, kitchen, laundry, an office and three bedrooms, one of which is shared. There is also a bathroom and toilet. The first floor is accessed by stairs or lift, and comprises nine bedrooms, two of which are shared, and a bathroom and three toilets. There is car parking to the side and rear of the property, accessed by a gravel driveway, and the rear gardens are laid to lawns. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3.5 hours, it was unannounced and was carried out by two inspectors. A tour of the premises was conducted, service users care records and staff records were inspected. Inspectors spoke with the acting manager and the home administrator. One service user was spoken with and one service users representative. What the service does well: What has improved since the last inspection? What they could do better: The homes communication systems must be improved as the acting manager was unaware of the requirements placed upon the home following the previous inspection visit and was not aware of several of the homes policies/procedures and some administrative systems. Also, there is a lack of structured staff supervision. Service users are being put at potential risk as a comprehensive assessment of each individual’s care needs is not undertaken and care plan information does not clearly document individual’s care needs or instruct staff regarding how these are to be met. Adult protection policies and procedures are not up to date and therefore do not provide staff with the correct guidance. Complaints procedures are not fully adequate. The registered person must ensure that all money and valuables deposited by service users for safe keeping are accurately recorded. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 6 The homes bathing and toilet facilities are inadequate overall to fully meet the care needs of service users and hoist servicing records could not be located during the visit. Fire safety systems are not tested as per fire safety regulations and a risk assessment is required regarding the prevention of fire and legionella. 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. Holland House C53 C04 S2373 Holland House V225425 200705 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 Holland House C53 C04 S2373 Holland House V225425 200705 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 Procedures for the assessment of service users and for their admission to the care home are not being fully followed, therefore service users cannot be assured that their care needs will be met. EVIDENCE: The acting manager said that service users care records were currently being updated. Two service users files were seen and some improvements have been made regarding the management of these since the previous inspection visit. Service users are issued with a contract of stay. Information within the care records inspected was too brief and did not fully identify each service users care needs or all potential risks to enable a detailed care plan to be devised. One service user was being treated for pressure area relief although tissue viability was not fully documented within their care plan. The care records viewed did not fully document that service users had been notified that the care home was able to meet teach individuals care needs. Holland House C53 C04 S2373 Holland House V225425 200705 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, 10, 11 Care records overall do not provide staff with sufficient information to meet service users care needs or fully document the care provided. EVIDENCE: Service users have individual care plans, which only partially document how their assessed care needs are met. A risk assessment is completed for each service user although these do not identify all potential risks or the action to be taken by staff to minimise these. Care records are generally updated daily and reviewed on a regular basis although information following care reviews was not always transferred to the care plan and there were no records of service users wishes or requests regarding bereavement. The care plans viewed evidenced where residents were seen by health care professionals in relation to their health care needs. The service users representative spoken with their loved one was treated with dignity and respect. Comments included: “I believe the staff do care, my loved one is treated well”, “I am satisfied that they mean well and they do treat them well”. “There are no real rules or restrictions that I’m aware of”. During the visit members of staff were seen to treat residents with respect and sensitivity when delivering personal care. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 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 standard(s) 13, 15 Service users food choices and preferences are promoted. Service users can choose how they spend their time and there are no visiting restrictions. EVIDENCE: The acting manager said that there are no visiting restrictions and this was confirmed by the service user and representative spoken with. Comments included: “I visit here when I can and I’m always made welcome”. The homes records document the foods provided to each resident and the daily menu is displayed. The service users care records inspected evidenced individual likes and dislikes regarding foods. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 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 standard(s) 16, 18 The homes systems and procedures for the handling of issues of abuse and complaints are inadequate. EVIDENCE: A complaints policy is in place although there is no system in place to address informal complaints, which was identified during the previous inspection. The manager was unaware of the need to have an up to date copy of the Lincolnshire Adult Protection abuse awareness policies and procedures, which again had been raised during the previous inspection. The home has a whistle blowing policy, which was displayed in the office. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 25, 26 Some of the physical environment is not fully suitable to meet service users care needs and equipment service records must be maintained. EVIDENCE: The home has communal space comprising a lounge and dining area measuring 32.05 and 27.31 square metres respectively. There are two bathrooms and four toilets within the home. A fixed hoist is located in the upstairs bathroom, but the downstairs bath is too small to be used by service users having mobility difficulties. The acting manager said that this was due to be replaced with a walk-in shower. There is only one accessible toilet for service users to use downstairs. Therefore, staff assist service users in the upstairs toilet when this is in use, which causes inconvenience. The action plan provided by the home following a previous inspection stated that these issues would be discussed further, but no formal action has been taken. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 13 A risk assessment regarding legionella has not been completed, which was identified during the previous inspection although the home are preparing for a test to be undertaken. There were no unpleasant odours noted during the visit although carpet areas were not fully clean due to a faulty vacuum cleaner, which was addressed during the visit. The homes hoist service records could not be located during the visit. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 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 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, 29, 30 Some improvements have taken place regarding the recruitment and training of staff although staff must be adequately supervised. EVIDENCE: The staff rota demonstrates that 2 care staff are allocated to work on each daytime shift and that the acting manager has 2 supernumary days each week. The records of three staff members were inspected and appropriate checks had been undertaken for these individuals. Records of induction are maintained. A new system for the monitoring of training is being implemented, which more clearly identifies the training undertaken by staff, individuals training needs and forthcoming courses. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 15 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) 34, 35, 36, 38 The written and verbal communication systems in the home are not fully adequate to ensure that service users care needs are met. There are no formal systems in place to ensure that staff are appropriately supervised and working consistently as a team. Service users are put at risk through inadequate fire safety precautions. EVIDENCE: There is no formal supervision of staff and the acting manager was not fully aware of the homes policies and procedures to ensure that staff were appropriately meeting the service users care needs. Records regarding the homes testing of the fire safety and emergency lighting systems were not adequately maintained, which was identified during the previous inspection. The homes fire risk assessment could not be located during the visit, which was identified during the previous inspection. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 16 Service users money is stored in a safe, and there are records of money paid in and expenditure although records were not fully accurate, which was identified during the previous inspection. Holland House C53 C04 S2373 Holland House V225425 200705 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 3 1 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 2 1 x x 1 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 x x x 3 2 2 x 2 Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 18 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(1c)13( 4c).. Requirement Timescale for action 10/08/05 2. OP4 3. OP7 4. OP22 14(1c)13(4c)12(1a)15(1&2) A full needs assessment must be completed for all service users who are admitted. Care assessments must detail all items included within standard 3. A comprehensive risk assessment must be completed for each service user (previous timescale of 31/01/05 not met). 14(1d) The regisered person must 31/08/05 confirm in writing to the service user that the home can meet the care needs (previous timescale of 31/01/05 not met).. 13(4c)14( A comprehensive care plan must 10/08/05 2)15(1&2) be completed for each service user, which must clearly identify each service users needs and demonstrate how these are met. The plan for every service user must be reviewed each month and updated on a regular basis. Service users and their representatives (where appropriate) must be involved in the devising of care plans where possible (previous timescale of 31/03/05 not met). 23(c) Confirmation is required of the 31/08/05 up to date servicing of the C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Holland House Page 19 5. 6. OP25 OP16 13(4) 22(8) 7. OP21 23(2j) 8. OP31 8(1) 9. OP35 17(2) Sch 4 10. OP38 23(4a&c) 11. 12. OP11 OP38 4 23(4a&c) homes hoists and lifting equipment. A risk assesment to prevent legionella must be devised. The registered person must devise a system for system for the recording of complaints, and the action taken (previous timescale of 31/03/05 not met). The registered person must provide an action plan to the Commission to confirm how accessible toilet facilities can be provided for service users using the lounge and dining rooms (previous timescale of 31/03/05 not met). The registered person must ensure that a suitable person is put forward to become Registered Manager of the home (previous timescale of 31/03/05 not met). The registered person must ensure that all money and valuables deposited by service users for safe keeping are accurately recorded (previous timescale of 31/01/05 not met). The registered person must take adequate precautions to prevent the risk of fire. Therefore, all fire system must be completed as per the instructions of the Fire Safety Officer (previous timescale of 31/01/05 not met). Service users wishes regarding death must be recorded. A fire risk assessment must be undertaken 31/08/05 31/08/05 31/08/05 27/07/05 21/07/05 21/07/05 31/08/05 22/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 20 No. 1. Refer to Standard Good Practice Recommendations Holland House C53 C04 S2373 Holland House V225425 200705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unity House The Point, Weaver Road off Whisby Road Lincoln, LN6 3QN 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 Holland House C53 C04 S2373 Holland House V225425 200705 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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