Inspection on 22/08/06 for Holland House

This inspection was carried out on 22nd August 2006.

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

Holland House 20/08/07

Holland House 06/04/06

Holland House 08/09/05

Holland House 20/07/05

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 Lincs PE6 8AN Lead Inspector Mick Walklin Unannounced Inspection 22nd August 2006 10:30 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 Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holland House Address 35 Church Street Market Deeping Lincs PE6 8AN 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) 01778 345677 www.countrycourtcarehomes.com Mr Abdulaziz Ali Kachra Mrs Wendy Dellaway Care Home 21 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (21) of places Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category OP to be admitted into Holland House Care Home when there are 21 persons within this category already accommodated within the home No one falling within category DE(E) to be admitted into Holland House Care Home when there are 3 persons within this category already accommodated within the home Service users admitted under category DE(E) should only be accommodated in the main home and not in the building know as The Barn. The maximum number of persons to be accommodated within Holland House Care Home is 21 6th April 2006 Date of last inspection 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 currently not in use. Accommodation is located on two floors of the three-storey building. 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 DS0000002373.V309289.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This second key inspection this year was undertaken using a review of all the information available to the inspector regarding the service history of Holland House, and through visiting the home. The visit took place over 7 hours. The registered manager was present during the visit, together with the company operations manager. The main method of inspection used was called case tracking which involved selecting three people who were living at the home, and tracking the care they receive through the checking of their records, discussion with them and care staff, and observation of care practices and interactions. A tour of the premises was conducted. Documents connected with the running of the care home were also inspected. The manager completed a pre-inspection questionnaire, and eight ‘Have Your Say’ leaflets were returned, which had been completed by residents assisted by staff. What the service does well: What has improved since the last inspection? The manager has attended an interview, and has now been registered by the commission. There has been good progress on the issues identified at the last visit. The Statement of Purpose has been revised, but this still needs more information about the home. There is a better assessment to identify peoples care needs, before they move into the home. Care plans contain better information, but need to improve further. The way that medicines are stored and given is safer. There is now a place to record any complaints. The health and safety issues identified during the last visit have been attended to, so the home is safer for residents. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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 Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments have improved, but one resident had been admitted with inadequate information to enable staff to confirm that her needs could be met. EVIDENCE: The Statement of Purpose and Service User Guide provide residents and prospective residents information about the home, and a Service User Guide is available in each bedroom. Both have been updated, but require some additional information to fully describe the current provision of care in the home. A new pre-admission assessment is in use, which has improved the information available to staff. This provides good information about personal care needs and preferred lifestyle. Two residents have been admitted to the home since the last inspection, one of whom was admitted on the day of the visit, as an emergency admission. Her niece had visited Holland House twice, and said that she had been impressed with the caring attitude of the staff. However, the Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 9 manager confirmed that no pre-admission assessment had been done prior to admission, and there was no written information or care plan available form the social worker at the time of admission. When the lady arrived with her niece, she was introduced to other service users, shown her bedroom and offered refreshments. Staff reassured her when she became anxious, and talked to her about what activities that she would like to do. A brief discharge summary from the lady’s previous care home came with her, and the manager talked to the niece to gain more information when she arrived. Holland House does not provide intermediate care, but The Barn is currently being refurbished to provide six intermediate care beds. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have improved, but not all contain sufficient detail to enable staff to fully meet the needs of residents. Arrangements with health providers are satisfactory, and residents are happy with the standard of care provided. Medication procedures are now more robust to prevent the risk of errors. EVIDENCE: Good progress has been made to update residents care plans, some of which had been incomplete at the time of the last visit. There are a good range of assessments and information about preferred routines, likes and dislikes. Good daily records are maintained. Two of the care plans inspected were for residents who had recently been admitted, but the third contained no evidence of monthly reviews, although a six-monthly review had been done by the social worker. Two of the resident’s care plans inspected did not fully reflect all the needs identified in their assessments. There is now evidence that residents, or their representatives are consulted about the care plan. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 11 Residents are registered with a local GP practice, and during the previous visit, a community nurse said that they have a good working relationship with the home. Staff have a good knowledge of the needs of residents, and are quick to refer any health needs. Medication administration record and storage are satisfactory. The flue pipe, which exits in the medication cupboard, has now been covered with a vent, making it more hygienic. Residents confirmed that staff respect their personal space. One said, “The ‘girls’ are very kind”, and another said, “The staff look after you well – they are nice people”. Interactions between staff and residents were observed to be relaxed and respectful. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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 the following standard(s): 12, 13 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides activities which residents enjoy, and there are good arrangements for receiving visitors. Catering arrangements reflect individual choices and needs. EVIDENCE: There are daily activities planned for residents. One said, “There is a lot to do – you don’t always want to join in everything”. Preparations were well underway for a summer fete, and residents said that they had enjoyed a strawberry tea and a culture night some weeks ago. The manager has made an effort to increase the number of outings available, and has arranged access to a Dial-aRide minibus with a tail lift. A number of relatives visited during the day, and all commented that they are welcome to visit at ant time, and are always well received by helpful staff. Residents praised the quality of the meals provided. One said, “I certainly have no complaints about the food”. Staff assisted residents appropriately during mealtimes, and offered alternative choices of food to a resident who did not want what was on the menu. They also provided good support to a resident Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 13 who did had been reluctant to eat anything, and encouraged her to eat some of her meal. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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 the following standard(s): 16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives have confidence in the manager to deal with any issues or complaints that they have. EVIDENCE: A copy of the complaints procedure is provided in each bedroom, and there is now a system for recording any complaints and concerns. There have been no complaints since the last visit, and concerns raised by relatives about the deteriorating health of one resident, were dealt with promptly by the manager. Residents and relatives said that they have confidence in the complaints procedure, and there is a book in the reception area for anybody to record their comments about the home or the standards of care. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 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 the following standard(s): 19, 21 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and well-maintained environment for residents to enjoy. EVIDENCE: Previous visits have identified that there is only one toilet downstairs for residents using the lounge and dining room, and some residents said that this could be a problem. A response from the provider in October last year stated that there was no room for an additional toilet. The commission has now agreed to remove this requirement, but information must be included in the Statement of Purpose and Service User Guide to accurately reflect the bathing and toilet facilities. There is an ongoing programme of redecoration and refurbishment. Residents stated that they are happy with their bedrooms, and they are encouraged to bring in personal items and furniture. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 16 The home was reasonably clean on the day of the visit, although one relative commented that the home was not always as clean as could be expected, with food crumbs often noticed on the floor. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate for the needs of residents, and low staff turnover provides continuity of care. EVIDENCE: The home runs on two staff per shift, including nights, with the manager working supernumerary for part of the time. One resident said, “The staff work very hard – they always seem to be busy”. There was one occasion when staff were busy in the kitchen, and a relative had to alert them that a resident required changing. There has been no turnover of staff since the last visit, which has given residents continuity of care, and staff know the needs of residents well. There is presently has a vacancy for a night carer. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 18 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 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has improved the organisation within the home, and the environment is generally safe for residents. EVIDENCE: Since the last visit, he manager has attended a fit-person interview, and has been registered with the commission. She continues to demonstrate enthusiasm for further developing the service, and is undertaking a National Vocational Qualification at level 4. A record of staff supervision is now kept, but this shows that some staff have not received supervision for three months. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 19 Following the last visit, some health and safety issues have been addressed. Denture cleaning tablets, which are potentially hazardous, are now stored securely. Those residents who are able to use these independently, have been risk assessed. The nurse call system could not be heard from upstairs, but a buzzer has now been installed to alert staff. A carpet in a bedroom doorway, which could have presented a trip hazard, has been secured. However, a carpet in a doorway between the hallway and the upstairs bathroom was not secured, and could present a hazard. Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 20 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 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x 3 x x x x 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 3 x x x x 3 x 2 Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 21 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 OP3 Regulation 14 Requirement The registered person must ensure that service users are assessed prior to moving into the home, to ensure that their needs can be met. The registered person must ensure that assessed needs are reflected in the service users plan of care, which must be reviewed on a monthly basis. The registered person must attend to the health and safety issue identified. Timescale for action 31/10/06 2. OP7 15 31/10/06 3. OP38 13(4) 31/10/06 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 Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 22 Holland House DS0000002373.V309289.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office 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 DS0000002373.V309289.R01.S.doc Version 5.2 Page 24 - 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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