Inspection on 15/12/04 for Hollins Park Nursing Home

Care Home For Older PeopleHollins Park Nursing HomeVictoria Road Macclesfield Cheshire SK10 3JAUnannounced Inspection15th December 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) Mrs Tamara Simmons 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), Physical disability (1) 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 21st November 2004 YES NO 11/05/04 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 315th December 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 SimmonsHollins 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. The 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. In accordance with statute there must be a Registered Mental Nurse on duty at all times. There are also care, 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. Wheelchair access is afforded 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 unannounced inspection took place on 15th December 2004. The findings were that most of the national minimum standards for care homes for older people had been met or partially met. Standards of care at the home were high, and feedback from service users at the time of inspection confirmed this view. Feedback was given to the home manager following this inspection to identify what requirements and recommendations were being made as a result of the inspection. Choice of Home (Standards 1-6) 4 of the 5 standards assessed were met. Prospective service users and their families are invited to visit the home before a decision is made about taking up long term residency there. Once a decision has been made for this, service users are issued with a written statement relating to the terms and conditions of residency at the home. Visitors spoken with on the day of inspection stated that they were happy with the care afforded to their relatives. 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. Care plans were in place for the identified needs/problems of the service users, and risk assessments had been devised where a risk had been identified. Daily records with regard to the service users health and welfare were informative. The arrangements for the safe handling, recording, storage, and administration of medicines were examined on both floors of the home at this inspection. A discrepancy in the stock levels of medicines for two service users on the ground floor unit was discovered, and similarly for another service user on the first floor unit. Medicines were found to be stored securely, and medicines with a limited life expectancy upon opening were found to be dated upon commencement of use. Staff were observed assisting service users in a friendly and supportive manner. Whilst the home has a policy regarding death and dying, this had not been addressed in the care records of one service user identified as suffering from a terminal illness. Daily Life and Social Activities (Standards 12-15) All 4 of the standards were assessed and were met. An activities co-ordinator employed at the home is responsible for the programming of social and leisure activities for the service users, and evidence was seen of events being arranged for the Christmas period. The home has an open visiting policy, and visitors present at the time of inspection told the inspector that they were made to feel welcome at the home. Complaints and Protection (Standards 16-18) 2 of the standards were assessed and were met. Hollins Park Nursing Home Page 6 No complaints have been recorded as being received at the home since the last inspection. Appropriate documentation with regard to the protection of vulnerable adults was in place at both nurse stations, and the deputy manager informed the inspector that it was her intention to provide training regarding this topic for all staff before the end of June 2005. Environment (Standards 19-26) 6 of the 8 standards assessed were met. The standards of décor and furnishings around the home have been well maintained, but the carpets in the two larger lounges are in need of replacement as they are noticeably stained and have not responded adequately to being shampooed. All parts of the home were visited at this inspection and found to be clean, tidy, and free of any unpleasant odours. There is a shortage of storage space in the home that has resulted in a shower room being used to store equipment. Handrails are fitted in the corridor areas and grab rails were in place within close proximity to the toilets. Bedrooms were comfortably furnished, and evidence was seen of a number of these being personalised. Staffing (Standards 27-30) 1 standard was assessed at this inspection and was met. The home employs trained nurses who are supported in the delivery of care to service users by a team of care workers. At the time of inspection there were vacancies for both trained and care staff, and agency staff were being used to maintain the staffing levels required. The standards not assessed at this inspection were met at the last inspection. Management and Administration (Standards 31-38) 7 of the 8 standards assessed were met. The home manager is a trained nurse who was currently undertaking training leading to an NVQ level 4 in management and care. A support group for service users families/representatives is held bi-monthly at the home, and a suggestion box is located in the main foyer of the home where visitors can deposit their suggestions. Service reports were in place for the fire alarm system, gas safety, and portable electrical appliances. There was however no risk assessment in place for a service user who had bed rails fitted to their bed.Hollins Park Nursing HomePage 7 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 1 13(2) OP9 The registered person must ensure that accurate records are maintained with regard 31/01/05 to the recording and administration of medicines to service users at the home. The registered person must ensure that suitable provision is made for storage for the 31/01/05 purposes of the care home. The registered person must ensure that the stained carpets in the larger lounges on both 18/02/05 floors of the home are replaced. The registered person must ensure that a risk assessment is carried out and documented 31/01/05 for all service users who have bed rails fitted to their beds.223(2)(l)OP19316(2)(c)OP24413(4)(c)OP38RECOMMENDATIONS 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 *Hollins Park Nursing HomePage 8 1OP11The registered person should make arrangements for the service users and/or their families wishes concerning terminal care be carried out, and that a record of their wishes in relation to this be made.* 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 9 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 NO YES YES YES NO NO YES NO YES NO YES YES NO YES NO YES NO YES 8 6 0 NO NO YES YES 27 11 15/12/04 09.00 07.25Hollins Park Nursing HomePage 10 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 11 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 extrasYESIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? There have been no significant 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. The home manager informed the inspector that a copy of the statement of purpose and service users guide is given to the family/representative of the service users, and a copy of the homes last inspection report is available upon request. Extras charged for over and above the weekly fee are for such services as hairdressing, newspapers, outings and holidays.Hollins Park Nursing HomePage 12 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? A statement of terms and conditions is provided to service users that identifies the services provided by the home, the room to be occupied, and the periods of notice required by both parties for termination of residency at the home.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next inspection.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 trained nurses and care staff for the provision of care to the service users. . Other healthcare personnel are also involved in the delivery of care, e.g. doctors and chiropodists.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? The home invites prospective users and their families to visit the home prior to a decision being taken about living there. The statement of terms and conditions issued to service users identifies that admissions to the home are initially on a trial basis.Hollins Park Nursing HomePage 13 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 14 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. 3 Key findings/Evidence Standard met? As part of the inspection process the inspector reviewed the care records of five service users. All of these contained assessments in relation to the safe moving and handling of service users, their nutritional needs, skin integrity, falls and mental state. Records were seen of the service users being weighed on a regular basis. In addition to these assessments each of the records reviewed contained assessments based on the activities of daily living that looked at each aspect of life on a physical, psychological and social basis. Plans of care had been devised and implemented addressing the identified needs/problems of these service users. 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) X 03 Key findings/Evidence Standard met? All of the service users are registered with a general practitioner and have access to the NHS facilities. Physiotherapy is included in the weekly fee and a physiotherapist visits the home weekly to provide treatment to those service users requiring it. Chiropody is also included within the fee, and an optician and dentist visit the home upon request.Hollins Park Nursing HomePage 15 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? There is a medicines storage room on both floors of the home and the inspector examined the management of medicines for both floors. Ground Floor Medicines administered to the service users were recorded on their individual Medicine Administration Record (MAR) sheets. Whilst reviewing the stocks of medicines held on the ground floor the inspector noted that there were four tablets of one particular medicine for a service user that could not be accounted for, and that there was a supply of a medicine for another service user that was not identified on their MAR sheet. (This medicine had been listed on the service users previous MAR sheet). It would appear that the service user has been receiving this medicine without a record being made of its administration. Medicine for another service user that is to be administered rectally was found stored in a wall mounted medicines cupboard. The information leaflet accompanying this medicine advises that the medicine should be stored at a temperature no higher than 22º C. A record of the room temperatures for this room was on display that showed a range of temperatures ranging between 22-25ºC. A medicines refrigerator is supplied in the room and the nurse was advised to store this medication in there, leaving out the dose to be given at the next administration time. First Floor When checking the MAR sheets of a service user the inspector noted that 23 doses of a medicine had been signed as administered to the service user. From the stock supplied, a total of five tablets should have been left, but when checked there were six tablets remaining. It would appear that the service users MAR sheet had been signed on one occasion indicating that the medicine had been administered when it had not. General Medicines were found to be stored securely, and medicines with a limited life expectancy upon opening were found to be dated upon commencement of use. See Requirement 1Hollins Park Nursing HomePage 16 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? During the course of this inspection the inspector observed staff interacting with service users in a positive and supportive manner. They were heard to address service users appropriately, and to ensure that their dignity and privacy were maintained when providing personal care.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. 2 Key findings/Evidence Standard met? The home has a satisfactory policy relating to the care of the dying, and the procedure to follow when death occurs. At the time of inspection, one service user was suffering from a terminal illness. A review of this service users care records showed that neither they nor their familys wishes concerning terminal care and arrangements after death had been recorded. See Recommendation 1Hollins Park Nursing HomePage 17 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 employed at the home for twenty hours a week is responsible for the programming and delivery of social and leisure activities for the service users. Specific events for the Christmas period included two church services, a staff carol service, visiting carol singers, and a Christmas party.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 inspector spoke with three sets of visitors during the course of the inspection, all of who were positive in their comments about the care their relative received. They also said that they are made to feel welcome by the staff when visiting.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? Many of the service users bedrooms had been personalised with items brought in with them when they moved into the home, e.g. photographs and ornaments. Arrangements are in place for the provision of independent advocacy for service users identified as requiring this service.Hollins Park Nursing HomePage 18 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? A cooked breakfast is provided three days a week, and a continental style breakfast of cereals/porridge, and toast on the remaining days. Lunch on the day of inspection was a choice of corned beef hash or salmon bake both of which were served with vegetables, followed by a dessert of rice pudding or ice cream. The evening meal was to be soup, shepherds pie, trifle or a chocolate éclair. The cook informed the inspector that toast, cereals or biscuits are provided for suppers. Visitors spoken with were complimentary about the standard of food provided.Hollins Park Nursing HomePage 19 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 0 0 0 0 0 0 0 3Key findings/Evidence Standard met? There have been no complaints received at the home since the last inspection.The homes complaints procedure that meets the standard required was on display at the home and copies of this were kept in the service users bedrooms.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next inspection.Hollins Park Nursing HomePage 20 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 YES 03 Key findings/Evidence Standard met? A copy of the Department of Healths document `No Secrets was in place in the nurse stations on both floors and in the home managers office. During the course of this inspection the inspector spoke with staff about their awareness of their role in relation to adult protection. All demonstrated knowledge on this subject and responded appropriately. Six members of staff have received training in adult protection from the companys training officer, and the deputy manager said that it was her intention to provide this training to the remaining staff by June 2005.Hollins Park Nursing HomePage 21 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. 2 Key findings/Evidence Standard met? The building complies with the requirements of the local fire service and environmental health department. At the time of inspection the corridors and bedroom doors on the first floor were being redecorated. The home employs a maintenance person for the routine maintenance of the home, and contractors are used for work of this nature that falls outside the experience and expertise of this person. The standard of décor and furnishings throughout the home have been well maintained. Grounds were kept tidy, and accessible to the service users with supervision. Whilst touring the building the inspector noted that a shower room on the ground floor was being used to store a number of chairs belonging to a service user. When this was discussed with the manager she informed the inspector that there was no other storage area available within the home for storing these items. See Requirement 2Hollins Park Nursing HomePage 22 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. 3 Key findings/Evidence Standard met? There are a total of four lounges in the home, two on each floor. And a designated smoking lounge on the ground floor. Handrails are fitted in the corridors and grab rails provided within close proximity to the toilets. Lighting and furnishings in communal areas is domestic in nature.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. These are accessible for service users, and are located in the living and bedroom areas. All of the baths are domestic in design, and a bath hoist is available for assisting those service users who experience difficulty getting into and out of a bath unaided. The inspector tested the hot water outlets to the baths and found the temperature of this to be within acceptable levels. 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? As identified previously, there are handrails in all corridor areas and grab rails fitted within close proximity to the toilets. Access to both floors can be gained by stairs or the passenger lift. A call alarm system is provided in all bedrooms, toilets and bedrooms that was found to be in working order on the day of inspection. Pressure relieving mattresses were fitted to the beds of service users who had been identified as being at risk of developing a pressure sore.Hollins Park Nursing HomePage 23 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 NO NO YES 33 0 8 0 33 00 0 8 03 Key findings/Evidence Standard met? The above room sizes were provided by the home. There is a wash hand basin in all of the bedrooms, and privacy screening was provided in all of the shared bedrooms.Hollins Park Nursing HomePage 24 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 the standards of décor and furnishings well maintained. New carpets have been fitted in the two small lounges on the ground floor and in the corridors on both floors of the home since the last inspection. However, the inspector noted that the carpets in the larger lounges on both floors were heavily stained, and was informed that these had not responded significantly when shampooed. 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? Rooms are centrally heated and low surface temperature covers are fitted to the radiators to reduce the risk of burns. Lighting in service users accommodation was domestic in character. The windows in rooms occupied by service users can be opened to allow natural ventilation and are fitted with restrictors to prevent injuries from falls.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. 3 Key findings/Evidence Standard met? All areas of the home were visited at this inspection and were found to be clean, tidy and free from unpleasant odours. One of the trained nurse employed at the home is the nominated nurse with regard to infection control. All of the service users and homes linen is laundered at the home. The laundry equipment is adequate for the needs of the home, and a new washing machine, two tumble dryers and a roller press have recently been provided. The inspector was informed that the staff in the laundry have received infection control training since the last inspection.Hollins Park Nursing HomePage 25 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 X 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 X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 784 X X 368.59.8 27 123 Key findings/Evidence Standard met? The home currently had 47 hours vacancy for trained nurses and 175 hours care assistant vacancies. Agency staff are used to fill any vacancies in the staffing levels required Apart from the nursing and care staff a team of ancillary staff are also employed at the home, i.e. catering, domestic, catering, laundry and maintenance personnel.Hollins Park Nursing HomePage 26 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 X X 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next inspection.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next inspection.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next inspection.Hollins Park Nursing HomePage 27 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 registered manager of the home is a trained nurse who has many years of experience of working in and managing a care home. She is currently undertaking training leading to an NVQ level 4 in care and management.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? Staff were positive in their comments about the style of management style employed at the home.Hollins Park Nursing HomePage 28 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 runs a support group for the families/representatives of service users. Information about the purpose of the group, i.e. support, advice and information is displayed in the main entrance foyer. The other purpose of this group is to encourage participation in the home, and fund raising. These meetings are held bi-monthly at the home. A suggestion box is located in the foyer where visitors can deposit their suggestions. 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 insurance with regard to employers liability, public liability, products liability and professional indemnity was on display that is valid up to September 2005.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 X X X3 Key findings/Evidence Standard met? Service users personal allowances received at the home are paid into an individual bank account. Receipts are obtained for any purchases made on behalf of a service user, and small amounts of cash are held at the home to enable these purchases to be made.Hollins Park Nursing HomePage 29 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? Induction training is provided for all new staff upon their commencement of employment. A programme of staff supervision has been established at the home whereby staff meet on a regular basis with their manager/senior to discuss practice issues and their career development.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 the service users were stored securely, and the homes records were well maintained and up to date.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? Satisfactory service reports were in place for the fire alarm and emergency lighting systems. Records were also seen of these systems being tested by the maintenance person on a weekly basis. A number of the test records for the emergency lighting system recorded that not all of them were operational at the time of testing. The home manager spoke with the company contracted for servicing the system and asked that an engineer visit the home to repair those lights not working. In the meantime the maintenance person working at the home discovered that the problem with the system was due to a `blown fuse. This was replaced and all lights were returned to full working order. A landlords gas safety certificate had been issued for the home in June 2004. The portable electrical appliances at the home had been tested in February 2004. When reviewing the care records of a service user who had bed rails fitted to their bed, the inspector noted that a risk assessment regarding the use of this equipment was not in place within the records. See requirement 4Hollins Park Nursing HomePage 30 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition None. CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateDenis CoffeySignature Signature SignatureHollins Park Nursing HomePage 31 Public reports It should be noted that all CSCI inspection reports are public documents.Hollins Park Nursing HomePage 32 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 15 December 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.Hollins Park Nursing HomePage 33 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 accurate Note: 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 26 January 2005, 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. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YES D.2Action plan was received at the point of publicationYESAction 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 planYESOther: enter details here Hollins Park Nursing HomePage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr N Farmer of (Hollins Park Care Home), Community Health Services Ltd, 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 (Hollins Park Care Home), Community Health Services Ltd, 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 35 Hollins Park Nursing Home / 15th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000018801.V201379.R01© This report may only be used in its entirety. 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