Inspection on 06/04/06 for Holland House

This inspection was carried out on 6th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holland House 20/08/07

Holland House 22/08/06

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 Key Unannounced Inspection 6th April 2006 11:00 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 Holland House DS0000002373.V288556.R01.S.doc Version 5.1 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.V288556.R01.S.doc Version 5.1 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 Mr Abdul Kachra Care Home 21 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (20) of places Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 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.V288556.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information available to the inspector regarding the service history of Holland House, and through undertaking a visit to the home. The fieldwork visit took place over 7 hours. The main method of inspection used was called case tracking which involved tracking the care three residents receive, through the checking of their records, discussion with them and the care staff and observation of care practices and interactions. A tour of the premises was conducted with the acting manager. Documentation relating to the management of the home was also inspected. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose requires updating so that residents have up to date information about the home. Assessments and care plans should be more detailed to ensure that residents care needs are documented and met. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 6 Medication procedures should be more robust to ensure that medication is administered safely. The complaints policy should be updated, and a system for recording complaints and outcomes should be devised. Further consideration should be given to the provision of an extra toilet and a shower on the ground floor. Some health and safety issues require attention to ensure that the environment is safe. 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.V288556.R01.S.doc Version 5.1 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.V288556.R01.S.doc Version 5.1 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): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures for assessing residents prior to and following admission are not detailed enough to ensure that their needs will be fully met. Information available about the home requires updating to reflect management changes. 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. However, both need to be updated to reflect the current provision of care in the home, which the acting manager confirmed was happening. One resident, who had been admitted in January, had been assessed in hospital by the acting manager, with the involvement of the social worker and family. A copy a basic initial assessment was on her file, but a more detailed assessment had not been fully completed as yet. Previous inspections have Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 9 identified that the home does not write to prospective residents to confirm that following assessment, their needs can be met. However, a pro-forma letter has now been devised to confirm this. Holland House DS0000002373.V288556.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, 8, 9, 10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plan format has improved, but they do not yet 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 should be more robust to prevent the risk of errors. EVIDENCE: A new care plan format has been introduced, which will allow for comprehensive information to be recorded, relating to the support needs of residents. However, none of the three care plans inspected had been fully completed, and the acting manager explained that it was hoped to complete these shortly. Daily records are maintained, but there is no evidence of care plans being reviewed on a monthly basis, and no evidence of residents or their representatives being consulted. One resident said, “The staff provide good care – I don’t know what is in my care plan, but I trust staff to do their job”. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 11 Residents are registered with a local GP practice, and a Community Nurse was visiting at the time of the inspection. She 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. One relative complained that a letter had been sent out recently, which stated that relatives would be expected to escort residents to GP and Hospital appointments, or an hourly rate charge for staff escorts would be made. However, there is no mention of this in the resident’s contract, which states clearly what services are ‘extras’. The home uses a pre-packed administration system. Medication stocktaking and storage are satisfactory and well organised. However, a boiler flue pipe, possibly disused, exits into the medication cupboard, and is unhygienic. The temperature of the medication fridge is not recorded on a routine basis. Some morning medication had not been signed for at the time of administration, and it required that this be done to prevent medication errors. Residents interviewed confirmed that staff respect their privacy. One resident was receiving a visitor in her bedroom, and the Community Nurse was afforded privacy whilst seeing residents. The new care planning format has provision for recording resident’s wishes in the event of death, and all those inspected had been completed. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 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, 14 & 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: Those residents interviewed said that there are no restrictions on how they spend their time, and their individual preferences and wishes are respected. One said, “I’m fairly independent, so I don’t have to rely on staff to help me. I can choose how I spend my time”. Another said, “There is quite a lot to do – things are better now than they have been”. At the time of the inspection, residents were enjoying a music and movement session in the morning, a manicure in the afternoon. There is an activity plan, but this is flexible according to residents wishes and needs. A relative confirmed that she is able to visit regularly, and staff are friendly and welcoming, with refreshments being offered. One cook is currently employed, with another about to commence employment. The cook demonstrated a good knowledge of residents individual Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 13 likes, dislikes and nutritional needs. Menus are varied, and although there is only a choice of one main course, the cook explained that alternatives could be provided. Care plans contain information about dietary requirements, and nutritional assessments. However, it was noted that one resident was assessed as ‘medium risk’, but there was no care plan in place. Residents said that the standards of catering are good, and their choices are catered for. The Environmental Health Officer visited in December, and advisory matters were being dealt with. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have confidence in the complaints and protection procedures, and staff are aware of their responsibilities. EVIDENCE: One resident said, “I am happy with it all here”. She said that she had confidence in the acting manager to resolve any issues. A copy of the complaints procedure is provided in each bedroom, but this requires updating to reflect management changes. Staff demonstrated a basic awareness of the safeguarding adults procedures, and there was evidence of training updates. Copies of the relevant procedures are displayed in the office. Residents interviewed said that they feel safe and protected at the home. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 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, 22, 24 & 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, but toilet and bathing facilities are not adequate for the needs of residents. EVIDENCE: The home presents as well decorated and furnished, and all residents interviewed stated that they are happy with the standard of both the communal and individual accommodation. There has been a significant improvement in the standard of the environment over the past year. The home was clean and pleasant smelling, and a new cleaner has been recruited. 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 Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 16 additional toilet. Information must be included in the Statement of Purpose and Service User Guide to accurately reflect the bathing and toilet facilities. There are two baths, one of which is fitted with a fixed hoist. However the other bath is too small to be used. Previous action plans have indicated that a walk-in shower is being considered, but no action has been taken on this. The unsuitable door lock fitted to one of the bedrooms has been replaced, but the acting manager was not able to find the key promptly, which could be unsafe if access was required in an emergency. It is recommended that this situation be reviewed, and all staff be made aware of the location of the key. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 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, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training has improved, and arrangements for cleaning have improved. There are still issues about staff who are unable to fully communicate about residents care needs. EVIDENCE: The Barn is currently not being used as part of the care home, and there were 14 residents at the time of the inspection. The home runs on two staff per shift, including nights, with the manager working supernumerary for part of the time. Residents and relatives said that the staff are busy, especially at mealtimes, when an extra member of staff would be useful. Residents were complimentary about the staff, who they said were “friendly and helpful”. The previous inspection highlighted problems when staff had been on duty have not been able to understand what was being said. Although this was not identified as a problem on the day of the inspection, two visitors once again raised this as an issue. One person said that she had phoned the home, and the member of staff who had answered had hung up because they could not understand the conversation. The acting manager is undertaking training towards NVQ level 4 and the assessors award. Three other staff are working towards NVQ level 2. Regular Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 18 training updates are now available, with the area manager co-ordinating this. The acting manager is the moving and handling trainer for the group of homes. Training records are held centrally, so were not available at the time of the inspection, but some recent certificates were seen on staff files, together with evidence of induction. Three staff files were inspected, and all contained the documentation necessary for the protection of residents. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 19 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, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager is keen to further improve the home. Staff supervision has been introduced, and quality satisfaction questionnaires are in use. Some health and safety issues were identified which could potentially put residents at risk. EVIDENCE: The Commission has now received an application to register the manager, which is currently being processed. Staff confirmed that they now receive supervision from either the acting manager or deputy, but there were no records to evidence this apart from confidential supervision records. It is recommended that a record of sessions undertaken and planned is kept. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 20 Resident’s money is securely stored, and monthly audits are conducted. Three balances were checked, and all balances corresponded with the records kept. The home has a questionnaire, which is distributed to residents, relatives, friends and healthcare workers. Seventeen had been completed and returned, and all contained positive feedback, but none were dated so it was not possible to ascertain when the survey was conducted. Servicing and maintenance records inspected were up to date. Routine fire checks are now being carried out on a regular basis. A fire risk assessment has been completed, and it is recommended that the views of the fire officer be obtained to ensure that this meets fire regulations. Risk assessments have been carried out on the environment, but a tour of the building identified the following health and safety issues: • • • Denture cleaning tablets are stored in some resident’s bedrooms, and these must be risk assessed to ensure safe usage. The carpet in the doorway of bedroom 2 upstairs was not secured, and could present a trip hazard. The nurse call system cannot be heard when working upstairs, as the panel is situated in the dining room. There was no record of the system having been serviced in the last year. Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 21 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 2 x 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x 2 3 x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 2 Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4 (1) (2) and 5 (1) (2) Requirement Timescale for action 31/07/06 2. OP3 3. OP7 The registered person must produce statement of purpose and service user guide to include all of the items detailed in Standard 1 and Schedule 1 of the care home regulations and that this is made available to current and prospective service users. (previous timescale of 31/10/05 not met). 14(1c)13( The registered person must 31/07/06 4c)12(1a) complete a full needs 15(1&2) assessment for all service users who are admitted. Care assessments must detail all items included within standard 3. (previous timescales of 31/01/05 and 10/08/05 not met). 31/07/06 13(4c)14( The registered person must 2)15(1&2) complete a comprehensive care plan for each service user, which must clearly identify their 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 DS0000002373.V288556.R01.S.doc Version 5.1 Holland House Page 23 4. OP9 13(2) 5. OP16 22(8) 6. OP21 23(2j) 7. OP38 13(4) the devising of care plans where possible (previous timescales of 31/03/05 and 29/09/05 not met). The registered person must take the following action relating to medication administration and storage: • Ensure that debris from the boiler flue pipe is not able to contaminate medication. • Ensure that the temperature of the medication fridge is monitored on a regular basis. • Ensure that administration records are signed at the time of administration. The registered person must devise a system for system for the recording of complaints, and the action taken (previous timescales of 31/03/05 and 31/08/05 not met). The complaints procedure must be updated to reflect management changes. An action plan must be provided to demonstrate how adequate bathing and shower facilities will be provided. Information must be included in the Statement of Purpose and Service User Guide to accurately reflect the bathing and toilet facilities. The registered person must attend to the health and safety issues identified. 31/07/06 31/07/06 31/07/06 31/07/06 Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 24 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 OP24 Good Practice Recommendations It is recommended that the procedure for obtaining the key for downstairs bedroom No. 3 be reviewed so that it is readily available to staff in an emergency. It is recommended that a record of supervision sessions undertaken and planned is kept. It is recommended that the views of the fire officer be obtained to ensure that the fire risk assessment meets fire regulations. 2. 3. OP36 OP38 Holland House DS0000002373.V288556.R01.S.doc Version 5.1 Page 25 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. 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