Inspection on 09/11/05 for Hollins Park Nursing Home

This inspection was carried out on 9th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hollins Park Nursing Home 17/07/07

Hollins Park Nursing Home 03/10/06

Hollins Park Nursing Home 02/06/05

Hollins Park Nursing Home 15/12/04

Hollins Park Nursing Home 11/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hollins Park Nursing Home Victoria Road Macclesfield Cheshire SK10 3JA Lead Inspector Denis Coffey Announced Inspection 9th November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hollins Park Nursing Home Address Victoria Road Macclesfield Cheshire SK10 3JA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01625 503028 01625 503031 Community Health Services Limited Mrs Tamara Simmons Care Home 49 Category(ies) of Dementia (5), Dementia – over 65 years of age registration, with number (49), Physical disability (1) of places Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 49 service users to include: * up to 49 service users in the category of DE(E) (Dementia over the age of 65 years) * up to 5 service users in the category of DE (Dementia under the age of 65 years) * 1 named service user in the category of PD (Physical disability) The registered provider must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 02 June 2005 2. Date of last inspection Brief Description of the Service: Hollins Park provides nursing care for 49 residents suffering from dementia. Five of the 49 places can be used to accommodate residents under the age of 65 years. The 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. Each wing has a lounge, dining room and smaller lounge. There is passenger lift access to the first floor. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over a six-hour period that included a tour of the premises, inspection of care and general records, and speaking with residents and their visitors. The general care and health and safety of the residents is well managed, but there were areas where these were identified as needing improvement, i.e. the maintenance of more accurate care records and the storage of substances that could prove hazardous if used incorrectly. Residents and visitors spoken with were positive in their comments about the standard of care provided, adding that the staff were friendly and supportive. Survey comment cards were received prior to this inspection from five residents, two relatives, and one healthcare professional. Comments in these were positive about the standard of care, information available, and dignity and privacy issues. What the service does well: What has improved since the last inspection? The system for recording medicines to ensure that residents are administered their medicines as prescribed and that the stock levels of medicines is correct has been addressed in a positive manner. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 6 Fire safety precautions have improved with the inclusion of checking that the fire extinguishers are in good working order, and the repair of the emergency lighting system. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Residents are assessed and given information to make sure that they know their needs can be met at the home and what their rights and responsibilities are whilst living there. EVIDENCE: The home has a statement of purpose that was examined and found to meet the standard required. Residents are issued with a contract detailing the weekly fee payable, what services are included within the fee, and the arrangements in place for termination of the agreement by both parties. The contract also identifies that residents’ personal effects are insured for up to £1,000. Records were seen of residents being assessed by a trained nurse prior to them taking up accommodation at the home. The assessment addressed the resident’s previous and current medical history, nutrition, personal hygiene, elimination, communication, mobility, and skin condition. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 9 Hollins Park does not provide intermediate care so standard 6 does not apply. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 The care records of some residents were incomplete therefore it was not possible to see from these that all the care needs of the residents were being met. Medicines are well managed providing a safe system for ensuring that residents receive their medicines as prescribed. EVIDENCE: The care records of four residents were examined at this inspection. All of which contained assessments of skin condition, safe moving and handling needs, nutritional needs, and a falls risk assessment. None of the records seen contained a continence assessment or plans of care identifying the oral hygiene needs of the residents’. One of the care records examined was that of a resident who had recently developed a skin break to their sacral area. A plan of care had been devised for this problem, but a description as to the size and depth of this skin break was not included, nor was this information referred to in the daily records made on the resident’s health and welfare. Such information should be included in the care plan to enable staff to monitor whether or not the problem is responding to treatment. The records of a resident with a similar problem did however contain this information. Evidence Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 11 was seen of both these residents having pressure-relieving mattresses supplied to their beds. Another resident taking up residency at the home in August 2005 had a recorded weight on admission of 35.3 kg, and when next weighed in September their weight was recorded as 30.6kg. This resident’s plan of care in relation to nutrition had not been amended to reflect this loss of weight. The arrangements for the storage administration and recording of medicines was examined. Medicines with a limited life after opening were found to be dated upon commencement of use. A random sample of medicines was chosen for stock reconciliation and were found to be correct, and the medicine administration record sheets of the residents were filled in correctly. Medicines subject to stricter controls were also examined. Records of these were well maintained. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Social activities are organised, providing a range of interests for people living at the home. Residents’ are enabled to exercise choice, giving them a degree of control over their lives. Visitors can come into the home at any reasonable time. EVIDENCE: Social and leisure activities are provided for the residents that include; nail care, going out for walks, reading newspapers with them, dominos and card games. During the course of the inspection two groups of residents were observed taking part in painting and flower arranging. The home has an open visiting policy, and residents can receive their visitors in the privacy of their bedrooms should they so wish. Two sets of visitors were present during this inspection and were spoken with. They expressed satisfaction with the care provided, and said that they felt welcomed. Within the limits of their condition residents are enabled to exercise choice, e.g. what to wear, and when to go to bed and get up. The families of the residents provide advocacy for them, and independent advocacy is arranged for those residents identified as requiring this service. An independent Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 13 advocate for one resident was visiting the home at the time of inspection, and she commented positively on the staff’s attitude and the assistance given to her. Lunch on the day of inspection was a choice between fish or beef pie, both of which were served with mashed potatoes, carrots and peas. Toffee pudding and custard or bananas and custard were available for dessert. Staff were heard to ask residents what their preferences were from these choices. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Information is available to residents and visitors informing them of how to make a complaint and who to make it to. The home’s policies and procedures in relation to adult protection are available at the home for staff to ensure that residents are protected from abuse, harm and poor practice. EVIDENCE: A copy of the home’s complaints procedure is included in the statement of purpose, and a copy of this was on display at the home. There have been no recorded complaints being received at the home since the last inspection. The home has devised a protection of vulnerable adults training pack. This identifies the types of abuse that may occur, the signs of abuse, how to take action if abuse is suspected, and how to record such events. The telephone numbers of the Commission and the police are also given. The home’s deputy manager who has attended a course on how to ‘train the trainers’ provides the training in adult protection. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 25 & 26 The general standards of décor, furnishings and hygiene are good, providing residents with safe, comfortable and homely surroundings. EVIDENCE: The home employs a maintenance person for 37.5 hours per week and also have call on another person on a part time basis for attending to redecoration and painting work at the home. Grounds were tidy and accessible to residents from both floors of the home. The building complies with the requirements of the local fire service and environmental health department. The home provides adequate bathing and toilet facilities all of which are located close to bedrooms and day areas. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 16 Handrails are fitted in the corridors and grab rails within close proximity to the toilets. Portable hoists are provided on both floors for use with residents who are unable to walk independently. A call system is provided for summoning help in the bedrooms, sanitary annexes and day areas of the home. At the time of inspection an engineer was carrying out repairs to this, and before leaving the home, verified that this was in good working order. Thermostatic valves are in place to regulate the temperature of the hot water supplied to the baths, and when tested, the temperature of the water was within acceptable limits. All of the rooms occupied by residents are centrally heated, and have windows that can be opened to provide natural ventilation. Emergency lighting is provided throughout the home. All parts of the home were visited at this inspection and found to be clean and tidy. There was a distinct unpleasant smell present on the main corridor on the top floor at mid morning. When revisited early in the afternoon this smell was not as pronounced following cleaning of the carpet in this area. See Recommendation 1 Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 There are enough staff rostered to be on duty to meet the needs of the residents at all times. Recruitment procedures include thorough checks of all new staff which are needed to ensure that the residents are protected from any possible harm. EVIDENCE: Apart from the manager and deputy manager the home employs the equivalent of 9.44 full time trained nurses, and 21.77 full time equivalent care assistants. Because of being able to recruit to empty posts, there is less reliance on agency staff to maintain the agreed staffing levels. Nine of the care staff employed at the home have attained an NVQ level 2 in care (one of whom has also achieved this award at level 3), and two of the bank care staff have also attained an NVQ level 2. Seven of the care staff are currently undertaking training leading to this award. Two of the domestic and one of the laundry staff have successfully completed the NVQ level 1 course in cleaning and support services. The personnel records of three staff employed at the home were examined and found to contain the necessary documentation to ensure that residents’ are supported and protected. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 18 The manager produced information regarding staff training for the year that included safe moving and handling, non violent crisis interventions, the protection of vulnerable adults, first aid, nutrition and wound care. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 35 & 38 The home is well managed and there are clear lines of accountability to ensure that the health and safety of residents and staff are protected. However, there is one area where this could be improved upon. There is no formal quality assurance structure in place to inform the home on the standards delivered. EVIDENCE: The registered manager is a registered mental nurse who has completed the registered managers award. There are clear lines of accountability within the home and with external management. There is no formal quality assurance system in place at the home. Family’s views are sought when they attend the care reviews of their relatives but the information gained is not collated to ascertain the quality of the service provided overall. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 20 Some of the residents’ personal allowances are paid directly to the company, and when residents require money the home request this from the company’s head office where it is kept in individual savings accounts. The relatives of other residents deposit small sums of money for the purchasing of personal items, e.g. toiletries, chocolate and cigarettes. The finance records of four residents were examined. All of these contained records of money received and money spent along with appropriate receipts. When counted, the balance of cash held for these residents was found to be correct. Records were seen of staff receiving fire safety instruction, health and safety training, and training in the safe moving and handling of residents’. A fire risk assessment of the premises had been carried out in May this year. The fire logbook showed that the fire alarm system was tested weekly and the emergency lighting system, monthly. A record was also maintained of a visual inspection of the fire extinguishers being carried out on a weekly basis. The home was in receipt of the following current safety certificates: • • • • Gas safety. Water disinfection. Passenger lift worthiness. Portable electrical appliance testing. The door to a storage room where cleaning materials are kept on the ground floor was observed to be open. Staff were not in the vicinity of this area and residents could have wandered into the room and used these products inappropriately. There was a bolt on the outside of the door but this was broken. The products in question are subject to the control of substance hazardous to health legislation and should therefore be stored securely at all times. See Requirement 2 See Requirement 3 Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Timescale for action Suitable plans of care must be in 15/12/05 place addressing all of the identified needs of the residents in relation to their health and welfare. This requirement remains outstanding from the previous inspection. A system must be established for 31/12/05 reviewing the quality of care provided at the home. All substances identified as being 30/11/05 hazardous to health must be stored securely at all times. Requirement 2 3 OP33 OP38 24 13 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations Alternative methods of cleaning the carpets should be investigated in order to fully eliminate the presence of unpleasant smells at the home. Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hollins Park Nursing Home DS0000018801.V250054.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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