Inspection on 11/05/04 for Hollins Park Nursing Home

Care Home For Older PeopleHollins Park Nursing HomeVictoria Road Macclesfield Cheshire SK10 3JAAnnounced Inspection11th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Hollins Park Nursing Home Address Victoria Road, Macclesfield, Cheshire, SK10 3JA Email address Name of registered provider(s)/company (if applicable) Community Health Services Limited Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 49 Tel No: 01625 503028 Fax No: 01625 503031 Manager.hollinspark@car euk.comCategory(ies) of registration, with (number of places) Dementia (5), Dementia - over 65 years of age (49) Registration number F010000506 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 25th November 2002 YES NO 17/02/04 If Yes refer to Part CHollins Park Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 311th May 2004 09:00 am Denis CoffeyID Code078141Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNot applicable at this inspection. Ms T Simmons.Hollins Park Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementHollins Park Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Hollins Park Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Hollins Park Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Hollins Park Nursing Home provides nursing care for 49 service users diagnosed with dementia, for long and short stay, and respite care. Five of the 49 places can be used to accommodate service users aged under 65 years of age diagnosed with dementia. There must be a registered mental nurse (RNM) on duty at all times. There are also carers, domestic, catering, and laundry staff employed. Hollins Park Care Home is a detached, two-storey purpose built property situated in its own grounds near to Macclesfield District General Hospital. It is approximately one mile from Macclesfield town centre. The accommodation comprises of four wings on two floors, with 33 single and 8 double bedrooms for 49 service users. Each wing has a lounge, dining room and smaller lounge. There is a passenger lift for access to the first floor. There is wheelchair access to all areas.Hollins Park Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This announced inspection took place on 11th May 2004. The findings were that many of the National Minimum Standards had been met or partially met, and that the overall standard of care provided was good. Choice of Home (Standards 1-6) All of the 5 standards assessed were met. Prospective service users and their families are invited to visit the home prior to making a decision about taking up residency. Admissions are made initially for a trial period, and service users are issued with a written statement identifying the terms and conditions of residence at the home. The inspector spoke with three sets of visitors who were in the home at the time of this inspection. They were positive in their comments with regard to the home in general and the standard of care provided. Health and Personal care (Standards 7-11) 3 of the 5 standards assessed were met. As part of the inspection process the inspector reviewed the care records of five service users. All of these contained a range of plans of care identifying various needs/problems of the service users, together with planned interventions for how these could be met. However, there were two instances where the needs of the service users in relation to specific problems had not been fully addressed. Records were seen of other healthcare personnel being involved in the provision of care. The arrangements for medicines were checked and found to be well managed with one exception, as noted in the main report. An activities coordinator is employed to arrange social and leisure activities for the service users. Staff were seen to be friendly and supportive to service users when assisting them with various aspects of their daily lives, and visitors spoken with said that they are made to feel welcome upon entering the home. Daily Life and Social Activities (Standards 12-15) All of the standards were assessed and were met. An activities co-ordinator is employed at the home to provide a range of social and leisure activities for the service users. The home has an open visiting policy. Visitors present at the time of inspection told the inspector that they are able to visit when they wish, and that they are made to feel welcome upon entering the home.Complaints and Protection (Standards 16-18) Hollins Park Nursing Home Page 6 All 3 of the standards were assessed and were met. The homes complaints procedure meets the standard required, and copies were provided to the service users. Adult protection issues are discussed with staff during their induction training, and a copy of the Department of Healths document `No Secrets is available in the managers office. Environment (Standards 19-26) 5 of the 8 standards assessed were met. One of the boilers at the home had burst two weeks before this inspection and had been repaired. A result of this burst was that some of the carpeting on the ground floor had become water stained and damage was also done to some of the décor on this floor. The home manager informed the inspector that new carpeting and redecoration of these areas would take place once an insurance assessor had visited the home to assess the damage. Apart from this, the standard of décor and furnishings at the home had been well maintained. Staffing (Standards 27-30) All 4 of the standards were assessed and were met. A review of the staffing rotas showed that the agreed staffing levels are being complied with. Various training initiatives have been arranged for the staff that include care staff undertaking NVQ level 2 in care. Management and Administration (Standards 31-38) 7 of the 8 standards were assessed and were met. The home manager has been in post for a number of years and is currently undertaking the registered managers award training course, and has also applied to the Commission to be the registered manager at the home. The arrangements for the handling and accounting of service users personal money was examined and found to be satisfactory. Systems are in place for the maintenance of equipment, and fire safety. However, the inspector noted that the risk assessment for the use of bed rails for one service user did not fully identify the risks involved in the use of such equipment.Hollins Park Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 2 16(2)(c) OP24 The registered person must ensure that remedial attention is given to all carpets identified.Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 2 OP24 The registered person should give consideration to improving the lighting in the lounge identified.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). None.Met (Yes / No)Hollins Park Nursing HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The registered person is requested to provide the Commission with an action plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 15(1) & (2)(b) The registered person must ensure that the service users plans of care are kept under review, and that the plans must identify in full 30/06/04 how the service users needs in respect of their health and welfare are to be met. The registered person must ensure that the instructions on the service users Medicine 04/06/04 Administration Record sheets match those given on the medicine bottles. The registered person must ensure that the corridor carpet identified within the main body 30/06/04 of the report is replaced. The registered person must ensure that staff employed at the home receive training on the 31/07/04 procedures to be followed for the laundering of infected linen. The registered person must ensure that the risk assessment used for bed rails is amended to include the risks involved with 14/05/04 their use, and the correct fitting required for these.1OP7213(2)OP9316(2)(c)OP24413(3)OP26513(4)(c)OP38Hollins Park Nursing HomePage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The registered person should make arrangements for the medicine prescriptions to be returned to the home for checking before these are sent to the chemist for dispensing. The registered person should give consideration to providing additional copies of the Department of Healths document `No Secrets at the home, thus enabling access to this document by staff at all times. The registered person should give consideration to improving the lighting in the lounge identified. The registered person should consider the provision of an assisted bath at the home for those service users who experience difficulties in getting in and out of a domestic style bath.1OP92OP183OP204OP21* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Hollins Park Nursing HomePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES YES NO YES NO YES NO YES YES YES YES YES YES NO YES 9 3 1 NO YES YES YES 27 11 11/05/04 09.00 8Hollins Park Nursing HomePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Hollins Park Nursing HomePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · 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. Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 504 To (£) 546Any charges for extras If yes, please state what the extras are: Key findings/EvidenceYES Standard met? 3There have been no changes to the structure of the home, or significant changes in the homes staffing since the last inspection. The homes statement of purpose meets the standard required. Extras charged for over and above the weekly fees are for such services as hairdressing, newspapers, outings and holidays.Hollins Park Nursing HomePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Service users are provided with a written statement when they move into the home which provides details of the terms and conditions of residency. This statement identifies the services provided, the room to be occupied, the weekly fee, and the periods of notice required by both parties for termination of the contract. The statement also identifies that admissions to the home are initially on a trail basis. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? During the course of this inspection the inspector saw evidence in the service users care records of a pre-admission assessment being carried out by an appropriately trained nurse. The information gained at this assessment is then used to form the basis of the plans of care devised for the service user. Standard 4 (4.1 ­ 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home employs eleven registered nurses who are supported by a team of care staff. The staff were able to demonstrate that the service users health and welfare is monitored, and reviewed, and that they are able to provide for the needs of the service users, in conjunction with other healthcare personnel. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Prospective service users and their families are invited to visit the home before they decide to move in, but in the main it is the families who make such a visit. When prospective service users visit they are offered a meal, meet the staff, and are shown around the home. All admissions are made for a trail period. After that a review takes place to check that the placement is suitable for the service user and that all their needs can be met.Hollins Park Nursing HomePage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Hollins Park does not provide intermediate care.Hollins Park Nursing HomePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · The service users health, personal and social care needs are set out in an individual plan of care. · Service users make decisions about their lives with assistance as needed. · Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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. Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? As part of the inspection process the inspector reviewed the care records of five service users. All of the records reviewed contained a range of care plans addressing the identified needs/problems of the service users, and evidence was seen of these being evaluated on a regular basis. Assessments were in place for the service users skin integrity, and for their safe moving and handling. A daily record was made in relation to the service users health and welfare that was informative. One of the records reviewed was that of a service user who has a form of dementia that has a profound effect on their mood and behaviour. The inspector noted that a plan of care specific to this problem was not in place in the service users care records. The records of another service user stated that their breathing was worse because of physical deterioration. In conversation with one of the nurses the inspector learnt that this service user has a history of suffering from asthma, but this was not identified in their care records. See Requirement 1Hollins Park Nursing HomePage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence 6 1 Standard met? 3All service users are registered with a general practitioner and have access to the NHS facilities. At the time of the inspection one service user had a pressure wound. A physiotherapist visits the home twice a week to provide treatment for one service user, and other healthcare professionals are consulted and visit the home upon request, e.g. the stoma nurse, dietician, continence adviser, optician, and community psychiatric nurse. The weekly fees of the service users include the provision of chiropody and physiotherapy. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Medicines were found to be stored securely, and those medicines requiring it were stored in a medicines refrigerator the temperature of which was monitored daily. When examining the Medicine Administration Record (MAR) sheets of the service users the inspector noted that the administration instructions on one bottle of tablets did not match those given on the MAR sheet. The MAR sheet indicated that the service user should be given half a tablet once a day, whilst the bottle indicated that the service user should receive half a tablet four times a day. When asked about the system for ordering medicines the inspector was told that the nursing staff request these on carbon copies of the MAR sheets which are then sent to the doctor for the prescriptions to be written. These are then collected by the dispensing chemist from the doctors surgery. The inspector advised the nurse and the home manager that in order to minimise the risk of this happening again, the prescriptions should be returned to the home for checking before being sent to the chemist. Apart from this the MAR sheets of the other service users were found to be correct. A random sample of medicines chosen for assessing stock balances was also found to be correct. The nurse present at the inspection of medicines telephoned the inspector on the day following the inspection, confirming that the service users doctor and the chemist had been contacted, and the MAR sheet instructions and the label on the bottle of tablets now had the same administration instructions. See Requirements 1 & 2Hollins Park Nursing HomePage 17 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The home has a `Charter of Rights that refers briefly to privacy and dignity. Since the last inspection, a draft policy has been written specifically relating to privacy and dignity issues, which is currently being reviewed by the companys quality assurance manager. Staff were observed to respect the privacy and dignity of service users when attending to them, and to address them appropriately. During the course of this inspection the inspector spoke with three sets of visitors who told the inspector that they were satisfied with the care provided, and that they found the staff helpful and supportive. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The home has a detailed policy on death and care of the dying that includes the support to be given to relatives at such times. At the time of inspection none of the service users were suffering from an acute physical illness.Hollins Park Nursing HomePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · 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. Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? An activities co-ordinator is employed at the home for twenty hours a week to organise social and recreational activities for the service users. A range of board games and cards are available at the home, and reminiscence sessions are also provided. Barge trips have been organised for groups of four service users at a time accompanied by four members of staff, with relatives invited to go along on these. A barbeque has been planned for the summer. Outside entertainers, e.g. dancers, musicians and singers are booked periodically throughout the year to provide entertainment for the service users at the home. On the day of inspection, three of the service users attended out patient appointments at the local hospital and were accompanied at these by the activities co-ordinator who made these visits into social occasions by taking the service users to a café for coffee. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The home has an open visiting policy, and visitors spoken with said that they are made to feel welcome when entering the home. During the course of this inspection two sets of visitors took service users out for short trips. Service users who are physically able are accompanied by staff on shopping trips, visits to a local garden centre, and for pub lunches.Hollins Park Nursing HomePage 19 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users are encouraged to bring personal items with them when they move into the home, and the inspector saw evidence of many bedrooms being personalised with photographs and ornaments. The home manager informed the inspector that independent advocacy can be arranged through Age Concern for any service user identified as requiring such a service. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The home is currently trying a range of cooked, frozen food that requires reheating before being served. These meals are prepared by an outside catering company which provides a four weekly menu. This menu identifies the nutritional content and value of each meal, and when reviewed by the inspector, the menus appeared varied and nutritious in content. Service users commented positively on the standard of food provided, and staff told the inspector that a number of service users had gained weight since the introduction of this service. Breakfast is a choice of cereals or porridge, followed by toast and a hot drink. Lunch is the main meal of the day, and on the day of inspection this was a choice of either goulash or meat pasties, both of which were served with potatoes, vegetables and gravy. A dessert of chocolate chip sponge and custard or raspberry jelly was served at this meal. The evening meal was to be Lancashire hotpot or soup and sandwiches followed by a dessert of mousse or trifle. Suppers consist of such items as sandwiches, toast or biscuits, and fresh fruit is provided twice a week. A cook is employed at the home who in addition to preparing these meals also caters for any special diets required.Hollins Park Nursing HomePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · 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. Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence 1 0 0 1 0 0 100 3Standard met?The home maintains a complaints log for recording any complaints made. No complaints have been logged since the last inspection. A copy of the homes complaints procedure is kept in the service users bedrooms, and a further copy was on display in the entrance foyer. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Prior to forthcoming elections the home receives a list from the electoral officer containing the names of the service users, asking which of the service users are capable of exercising a valid vote. Where service users are identified as being able to take part in the electoral process they are assisted with this by the home.Hollins Park Nursing HomePage 21 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES 0 3Staff receive training on adult protection/abuse issues during their induction training. A copy of the Department of Healths document `No Secrets is available in the home managers office, and a Whistle Blowing policy is in place advising staff on how to make any concerns they may have, known. The inspector discussed with the home manager the benefit of providing a copy of the `No Secrets document at each of the nurse stations in the home, where they would be more accessible to the staff to read. See Recommendation 2Hollins Park Nursing HomePage 22 EnvironmentThe intended outcomes for the following set of standards are: · 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. Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home employs a full time maintenance person who assumes responsibility for the general maintenance of the home. This persons responsibilities are identified in a schedule of work that identifies daily, weekly and monthly duties. The inspector saw evidence of signatures verifying that these tasks had been completed. A decorator is also employed on a `as and when basis. At the time of inspection this person was present in the home carrying out remedial work to the doors on the ground floor. The enclosed garden at the back of the home was well maintained. There is a passenger lift for service users to access both floors of the home.Hollins Park Nursing HomePage 23 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 2 Key findings/Evidence Standard met? There is adequate communal space in the home for the number of service users accommodated that are accessible for all service users including wheelchair users. Furnishings provided were maintained well and were domestic in character. At the last inspection the inspector noted that the lighting in one of the lounges appeared dim, and a recommendation was made that the lighting in this lounge be improved. There was no discernible difference in the lighting at this inspection, and when this was pointed out to the home manager she said that she thought that higher wattage bulbs could not be used with the fittings or shades provided. She confirmed that she would ask for this to be checked, and if higher wattage bulbs could be used, then they would be supplied. See Recommendation 3 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? The home has sixteen toilets, four baths and four showers. All of the baths are domestic in design and a bath hoist is available for assisting those service users who have difficulty getting into and out of a bath. Whilst this aid is useful, it can prove frightening to some service users who experience difficulty in comprehending what is happening to them at such times. The provision of a bath designed specifically for service users who experience difficulties of this nature would be of benefit to them. A shower trolley is provided for a service user who cannot be bathed or showered in the usual manner because of their condition. See Recommendation 4 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? There are handrails in all corridors, and grab rails are in provided close to the toilets. The home has four mobile hoists for the moving service users safely. A call alarm system is provided in all bedrooms, toilets and bathrooms. It was in working order at the time of inspection and was responded to quickly when tested by the inspector.Hollins Park Nursing HomePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence NO NO YES 33 0 8 0 Standard met? 3 33 00 0 8 0The above room sizes were provided by the home. There is a wash hand basin in all of the bedrooms, and privacy curtains are provided in the shared bedrooms.Hollins Park Nursing HomePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? Bedrooms were comfortably furnished, and privacy curtains were provided in the shared bedrooms. One of the boilers at the home had burst two weeks before this inspection (and had been repaired by the time of this inspection). As a result some of the corridor carpets had become stained with watermarks, and the decoration was damaged on some of the corridor walls. The home manager told the inspector that the company was awaiting a visit from an insurance assessor following which the carpets would be replaced, and the décor made good. At the last inspection the inspector noted that the carpet in one of the corridors was taped down where it abutted to an adjoining carpet. This carpet continues to be taped down in two places with black masking tape, and is unsightly, and a potential hazard to service users tripping on it if the tape lifts. This carpet was noticeably stained and the inspector was told that these stains were not removed when the carpet had been shampooed. Therefore, this carpet must now be replaced. See Requirement 3 Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Low surface temperature covers are fitted to all radiators to reduce the risk of burns. Emergency lighting is provided throughout the home, and records showed that this is tested monthly. All parts of the home occupied by service users have windows that open to provide ventilation. The temperature of the hot water to the baths was tested during this inspection and found to be within acceptable limits.Hollins Park Nursing HomePage 26 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? All bedding and the personal clothing of the service users is laundered at the home. The laundry is equipped with two washing machines both of which have a sluicing facility, and three tumble dryers. The personal laundry of service users is returned directly to their bedrooms and put away. Laundry staff have developed a system for managing the volume of laundry received each day that appears efficient and well organised. However, when asked how infected linen would be treated they informed the inspector that they would ask the home manager or her deputy for advice. When asked if they had received training with regard to infection control, they told the inspector that they had not. The inspector saw records of all the refrigerators and freezer temperatures at the home being monitored twice a day. The records showed the temperatures were maintained at acceptable levels. The cook tests the temperature of all frozen produce on delivery, and of the hot food before it is served. Records were seen of these tests. A kitchen-cleaning schedule is in operation that identifies which areas require cleaning on a daily and weekly basis. Evidence was seen of this work being signed as completed. See Requirement 4Hollins Park Nursing HomePage 27 StaffingThe intended outcomes for the following set of standards are: · 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 homes recruitment policy and practices. · Staff are trained and competent to do their jobs. Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 27 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 18 0 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 1146 X X 3619.6 27 12 Standard met? 3A review of the staffing rotas for the two weeks before this inspection showed that the agreed staffing levels were being complied with. The home has some vacant staff posts that are currently being advertised in the local job centre and newspaper. Until these vacancies have been filled, an average of 130 hours per week is being provided by agency nurses and care staff.Hollins Park Nursing HomePage 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence 9 35 Standard met? 3As reported at the last inspection, seven of the care staff are currently undertaking training leading to an NVQ level 2 award in care, and are due to complete this course this year. Three more carers have been identified to start this course when the others have completed. If all of the staff currently undertaking this training are successful, then more that 50 of the care staff will have attained the standard required. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The inspector selected the personnel files for a trained nurse and a carer for review. Both contained two satisfactory references, documentary evidence of their identity, completed application forms, a medical declaration form, and a satisfactory enhanced Criminal Records Bureau disclosure. Neither contained a photograph of the person, and when this was pointed out to the home manager she said that this would be dealt with within the following two weeks. All trained nurses are required to maintain and renew their registration with the Nurses and Midwives Council every three years, and records were seen of the home checking that all the nurses employed were currently registered.Hollins Park Nursing HomePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? The inspector was informed of the following training initiatives available to the staff at the home: · Supervisory management training organised by a college of further education for the trained nursing staff to be held in July 2004. · Safe handling of medicines later this month provided by Stockport College for the trained nursing staff. · Non-violent intervention techniques for all staff. This training is to be undertaken by two members of staff employed at the home who have received accreditation in the provision of this training. · Alzheimers awareness training for all staff. This training is to be conducted by one of the trained nurses who will show the video that accompanies the training pack, followed by a discussion. Staff are then to be given a questionnaire to fill in, that will then be sent to the Alzheimers society where it will be assessed, and the results sent back to the staff. The deputy home manager is an accredited moving and handling trainer and assumes the responsibility for ensuring that all staff employed at the home receive training in safe moving and handling techniques annually. When they start work at the home, all new staff are provided with an induction-training workbook. This is divided into three sections. Section 1 addresses the principles of care and maintaining safety in the workplace. Section 2 provides more detail on the principles of care, working relationships, policies and procedures, and the role of the worker. Section 3 is an assessment of learning record filled in by the employee.Hollins Park Nursing HomePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · 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 homes record keeping policies and procedures. · The health, safety and welfare of service users and staff are promoted and protected. Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The home manager is a registered mental nurse and has been in post since 1997. She has recently commenced the registered managers award training course, and has applied to the Commission to become the registered manager of the home. She is due to be interviewed with regard to this application in June 2004. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The management style observed appeared open and inclusive. Staff spoken with were positive in their comments on how they were managed, and that they found the manager supportive.Hollins Park Nursing HomePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The home manager informed the inspector that she had recently attended a workshop on quality assurance issues. This was organised by the company which owns the home, and it is intended that a representative of the company will carry out unannounced visits to the home to audit the quality of the service provided. A representative of the company is also required to visit the home monthly on an unannounced basis to inspect the premises, its records of events, and prepare a written report on the conduct of the home. Records of these visits taking place were seen by the inspector. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? A certificate of employers liability insurance was on display that is valid up to September 2004. The companys insurance policy also covers the personal effects of service users up to a maximum of £1,000 per service user.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 3 1 0 1The home receives the personal allowances for some service users in the form of weekly cheques. These are sent on to the companys head office, where the allowances are paid into individual bank accounts for each service user. Copies of the bank statements are sent to the home. Small amounts of money are held at the home for purchasing personal items for the service users. This money is kept in a separate wallet together with receipts for any expenditure made. The inspector examined the cash balances for three service users and found these to be correct.Hollins Park Nursing HomePage 32 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? A programme of staff supervision has been initiated at the home where members of the staff have the opportunity to meet with their manager/senior to discuss the philosophy of care, aspects of practice and their career development needs. The home manager informed the inspector that staff will receive six such supervision opportunities each year. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? The personal and care records of service users are stored securely, and the homes records were well maintained and up to date.Hollins Park Nursing HomePage 33 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The following records were seen: · · · · · · · A satisfactory certificate of inspection for the electrical appliances in the home dated February 2004. A service of the passenger lift carried out in April 2004. The fire safety systems being tested by contractors in February 2004. Fire safety training for the nineteen staff since the last inspection. Three fire drills being conducted this year. Servicing of the mobile hoists in March 2004. The fire alarm system being tested on a weekly basis.The inspector reviewed the service users accident records for the period 24th March 2004 to 11th May 2004. A total of thirty nine accidents had been recorded during this period, six of which were attributed to aggressive incidents between service users. The majority of the accidents recorded were falls or incidents of service users being found on the floor. One record referred to a service user being trapped between the mattress and the bed rails fitted to their bed. When reviewing the risk assessment for the use of bed rails the inspector noted that the risk of entrapment, or how the rails were to be correctly fitted was not identified. Materials subject to the Control of Substances Hazardous to Health were stored securely in locked store cupboards. See Requirement 5Hollins Park Nursing HomePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition None. CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorDenis CoffeySignature Signature SignatureRegulation Manager Ann Gray Date 02.06.2004Hollins Park Nursing HomePage 35 Public reports It should be noted that all CSCI inspection reports are public documents.Hollins Park Nursing HomePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 11th May 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleHollins Park Nursing HomePage 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 1st July 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNOOther: enter details here Hollins Park Nursing HomePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Mr N Farmer of Community Health Services Ltd (Hollins Park Care Home), Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex, CO4 4YQ, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Mr N Farmer of Community Health Services Ltd (Hollins Park Care Home), Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex, CO4 4YQ am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Hollins Park Nursing HomePage 39 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!