Inspection on 08/09/05 for Holland House

This inspection was carried out on 8th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 David Bacon Unannounced 08 September 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 V248502 080905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holland House Address 35 Church Street Market Deeping Lincs 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 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 V248502 080905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 20 July 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 now not in use. Accommodation is located 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 V248502 080905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4.5 hours, it was unannounced and was carried out by one inspector. A tour of the premises was conducted, service users care records and staff records were inspected. The inspector spoke with the acting manager and the home administrator. Three service users were spoken with, two service users representatives and a senior community nurse. Comments included: “I’m happy here and I don’t want to move”. “The staff are friendly and caring”. “I do visit here often and I know that my loved one is happy here”. “I have no real concerns, the care is good”. “There have been moments when things haven’t gone so well but generally the care is okay”. “We have visited here on a number of occasions and some staff could not speak or understand English, which worried me”. “The care seems to be good enough, we don’t have any major concerns”. What the service does well: What has improved since the last inspection? What they could do better: There is no registered manager in post, which was identified during previous inspections. The acting manager must be afforded sufficient supernumary hours to manage the home. Sufficient numbers of domestic staff must be on Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 6 duty throughout the day to maintain appropriate levels of cleanliness, health and safety within the home. Also, concerns were expressed that some staff were not always fully able to communicate service users care needs to their representatives or health professionals and therefore systems must be in place to ensure effective communications within the home. A risk assessment is required for all areas of the home including Legionella and fire tests and drills must be maintained as per fire safety regulations. The homes toilet and bathing facilities overall are not sufficient for the number of service users. A comprehensive assessment of each service users 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. Several of the homes policies and procedures are in need of being revised and updated including the statement of purpose, service users guide and informal complaints procedure. Medicines must be fully receipted as received into the home. 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 V248502 080905 Stage 4.doc Version 1.40 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 V248502 080905 Stage 4.doc Version 1.40 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) 1, 2, 3, 4, 6 The procedures for the assessment of service users during their admission to the care home are only being partially followed, therefore service users cannot be assured that their care needs will be met. EVIDENCE: A statement of purpose and service users guide have been produced and these are provided to service users although these do not accurately represent the homes current provision of care. For example, management arrangements and the homes key worker system. The service users records viewed did not clearly evidence that each service users care needs had been assessed prior to admission and the information within these was basic and not fully sufficient to inform a detailed plan of care. However, it is acknowledged that some minor improvements have been made since the previous inspection. A comprehensive risk assessment had not been completed for each service user and this information generally did not fully identify the risks to each service user. Care records did not document where service users or their representatives had been consulted with regarding the plan. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 9 There was no written confirmation given to service users stating that the home was able to meet their care needs. Service users are provided with written terms and conditions of residence contracts and signed copies are mostly maintained on the premises. The home does not provide intermediate care services. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 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, 9, 10, 11 Some minor improvements have been made regarding care recording systems although care records overall do not provide staff with sufficient information to meet service users care needs or fully record the care provided. The service users spoken with are satisfied with how they are treated. EVIDENCE: A care plan is completed for each service user and information within these is brief and does not adequately document how their assessed care needs are met. The care records viewed did not all document that a risk assessment had been undertaken for each service user. 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 and representatives spoken with were satisfied overall with standards of care within the home. Comments included: “You should know that the care is very good and this is due to the staff”. “My loved one is very Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 11 happy and settled here, there’s no real problem with the care, the staff are very good”.” Yes, they treat you with respect, as you would want”. “I have not always been satisfied with the care here but mostly and I like the staff”. The community nurse spoken with was satisfied overall with standards of care and that care staff followed any given instruction or advice but expressed concern that some staff had not been able to communicate fully verbally, which had created some difficulties. During the visit members of staff were seen to treat residents with respect and sensitivity when delivering personal care. A record is maintained of medicines administered to each service user although minor adjustments are required to date receipt medicines as received into the home and to fully document any medicines being disposed of. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 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, 14 Service users are partially supported to express their views regarding life within the home, the care they receive and they can maintain and develop community links as they prefer. The activities provided by the home are enjoyed by the service users spoken with. Relatives and friends of service users are made welcome in the home. EVIDENCE: The service users and representatives spoken with confirmed that they were no restrictions as to how they spent their time and that staff respected their individual wishes and preferences. Service users said that they enjoyed the homes provision of activities, which was further evidenced within the records of activities undertaken. Service users are partially consulted with about their likes and dislikes although they do not have sufficient opportunity to express their views as residents meetings are not held on a regular basis. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 13 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 not fully adequate although some improvements have been made regarding these. EVIDENCE: A complaints policy is in place although there is no system in place to address informal complaints, which was identified during the two previous inspection visits. The manager has recently secured an up to date copy of the Lincolnshire Adult Protection abuse awareness policies and procedures and staff have attended training regarding this subject matter. The home has a whistle blowing policy, which was displayed in the office. The service users and representatives spoken with confirmed that generally, they felt able to express their views regarding the care provided. Comments included: “You can approach the staff and I know my loved one likes the staff here but some staff have been unable to understand what is being said, which is unnerving”. “The staff are okay and they will listen, no complaints”. “I have had small gripes and they have listened and addressed these overall”. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 14 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, 21, 24, 25 Some of the physical environment is not fully suitable to meet service users bathing needs and equipment must be appropriately maintained although service users are satisfied with the environment. EVIDENCE: Service users personal accommodation was viewed, which was cleanly decorated and demonstrated where service users had personalised their room. Furniture is of a domestic style and is in good order. Environmental risk assessments are in place although these are not adequately reviewed. No unpleasant odours were detected during this inspection although the home was not sufficiently tidy and domestic staffing levels are inadequate. The external doors have security keypads to minimise risks to service users who may be prone to wandering. An unsuitable door lock was being used on bedroom 3, which must be removed. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 15 The proprietor confirmed that any requirements placed upon the home following the most recent inspection visits from the fire safety officer and environmental health officer’s inspections have been met although fire safety tests, drills and training was not undertaken as per fire safety regulations. The home has a shaft lift of which service records are maintained although these were not inspected during this visit. The home has adequate communal lounge and dining space. 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. A risk assessment regarding legionella has not been completed, which was identified during the previous inspection although a water tank test has recently been undertaken. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 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) 27, 30 There are insufficient numbers of domestic staff, appropriately deployed to allow them to maintain cleanliness and the upkeep of the home and the home manager must be afforded adequate supernumary time to manage the home. Systems are not in place to ensure that there is staff on duty at all times who are fully able to communicate about service users care needs. EVIDENCE: The service users and representatives spoken with confirmed that they were satisfied with standards of care. Comments included: “I’m satisfied with things here and I wouldn’t want to leave”. “The staff are caring and friendly and they give you the help you need”. “I visit often and I know my loved one is satisfied”. “The only problem is that there have been occasions where staff on duty have been unable to understand what is being said so I have called back later”. Inspection of the staffing rosta identified that only eight hours of domestic support was in place for the week of the inspection. The manager conformed that there were generally twelve hours each week allocated for domestic support. The rota also identified that the manager had only been afforded one day as supernumary to oversee the management of the home. All other shifts were worked overseeing care tasks which is insufficient. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 17 Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 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 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) 33, 35, 36, 38 There are no formal systems in place to ensure that staff are appropriately supervised and working consistently as a team although staff receive statutory training. The premises are not adequately risk assessed. EVIDENCE: There is no formal supervision of staff, which was identified during the previous visit. Service users and representatives spoken with were satisfied that they are supported to express their views regarding the home and some systems are in place to enable this. For example, quality satisfaction questionnaires. Service users money is stored in a safe, and there are records of money paid in and expenditure and records were fully accurate. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 19 A risk assessment of the premises had not recently been undertaken since 2003. Staff members attend statutory training although records of these are not sufficiently maintained to clearly detail the training undertaken by staff. Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 2 x 2 x x 2 2 x STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x 3 x 3 1 x 2 Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 21 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 OP1 Regulation 4(1&2) 5(1&2) Requirement Timescale for action 31/10/05 2. OP3 3. OP4 4. OP7 It is required that the statement of purpose is to include all of the items detailed within standard 1 and schedule 1 of the care home regulations and that this is made available to current and prospective service users along with a service users guide. 14(1c)13( 14(1c)13(4c)12(1a)15(1&2) 29/09/05 4c).. 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 29/09/05 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 29/09/05 2)15(1&2) be completed for each service user, which must clearly identify each service users needs and demonstrate how these are met. This must be reviewed each month and updated on a regular basis. Service users and their C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Holland House Page 22 5. OP9 13(2) 6. OP11 4 7. OP16 22(8) 8. OP19 23(4a&c) 9. OP21 23(2j) 10. OP22 23(c) 11. OP25 13(4) 12. OP31 8(1) representatives (where appropriate) must be involved in the devising of care plans where possible (previous timescale of 31/03/05 not met). The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines. Therefore, medication must be signed for as received into the building and as disposed of. Service users wishes regarding death must be recorded (previous timescale 31/08/05 not met). 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 take adequate precautions to prevent the risk of fire. Therefore, all fire safety tests, training and drills must be completed as per the instructions of the Fire Safety Officer. 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). Confirmation is required of the action being taken to repair the homes lifting equipment following the most recent service. A risk assesment to prevent legionella must be devised (previous timescale 31/08/05 not met). The registered person must ensure that a suitable person is 29/09/05 29/09/05 31/10/05 09/09/05 31/10/05 31/10/05 15/09/05 09/09/05 Page 23 Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 13. OP36 18(2) 14. OP27 18(1a) 12(1a) 15. 16. OP38 OP24 13(4c) 12(4a) 23(2a) put forward to become Registered Manager of the home (previous timescale of 31/03/05 not met). . The registered person shall ensure that at all times suitably qualified competent and experienced persons are working at the home. Therefore, all staff must receive supervision and records regarding this must be maintained. Sufficient numbers of domestic staff must be deployed throughout each day and the acting manager must be afforded sufficient supernumary time to manager the home. Also, systems must be in place to ensure that staff are able to fully communicate with others about service care needs. A risk assessment of the premises must be undertaken and regularly reviewed. The door lock on bedroom 3 must be suitable and meet fire safety regulations. 31/10/05 10/09/05 15/09/05 31/10/05 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 Good Practice Recommendations Holland House C53 C04 S2373 Holland House V248502 080905 Stage 4.doc Version 1.40 Page 24 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 V248502 080905 Stage 4.doc Version 1.40 Page 25 - 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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