Inspection on 23/02/06 for Holly Bank

This inspection was carried out on 23rd February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holly Bank 08/05/06

Holly Bank 29/09/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Holly Bank Holly Bank The Promenade Arnside Carnforth Lancashire LA5 0AA Lead Inspector Jane Strawbridge Unannounced Inspection 23rd February 2006 10:00 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 Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holly Bank Address Holly Bank The Promenade Arnside Carnforth Lancashire LA5 0AA 01524 761277 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) Agis Residential Care Homes Ltd Manager post vacant Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 31 service users to include: up to 31 service users in the category of OP (older people) The home should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 29th September 2005 Date of last inspection Brief Description of the Service: The home is situated on the promenade in the coastal village of Arnside and has views over Morecambe Bay to the Lakeland fells. The building comprises a pair of semi - detached Victorian villas that have been combined, adapted and extended for its current purpose. The residents are accommodated on all three floors which are served by a passenger lift. The building is well maintained and there is a small car park at the rear of the building. There are ample communal areas including a conservatory and sunroom. There are 27 single bedrooms; 18 of which have en-suite facilities, and two double bedrooms. The village has a range of shops and a post office within a short walk from the home. Public transport is available in Arnside for people who wish to use the rail, bus or taxi services. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of the home took place during a morning and early afternoon. Ms Ann Mason Denny the home’s Acting Manager was present throughout the inspection. Time was spent talking with the residents either in small groups or individually, with their visitors and with the staff on duty. We looked around all parts of the home and examined a selection of records relating to the day-to-day running of the home and the care of the residents. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 The admission procedures are thorough and include prospective residents and/or their representative visiting the home to ensure their needs can be met before they decide to move in. The conditions of residency are clearly set out to enable residents to understand what is expected of them after they move in. EVIDENCE: The manager or head of care take an information pack with them when they visit all prospective residents to tell them about the services offered by Holly Bank. They also make an assessment to find out if the home will be able to meet their care needs. All of the information is written in large print and the home’s most recent newsletter is included in the pack. The home’s service user guide is pinned to the notice board in the reception area and a copy is available in each room. All residents are offered the opportunity to visit the home before making a decision to move in and they are able to try it for a trial period before signing a permanent contract that sets out the terms and conditions of residence. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 9 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): 8, 11 The home has a clear and consistent care planning system to ensure that the residents’ health and social care needs are met in a way that promotes their privacy and dignity. EVIDENCE: The home has recently adopted a sophisticated new system for care planning. The manager said that she was pleased with the Standex system because it was easy to use and contained a comprehensive range of information about each resident’s health and care needs, medication records, individual interests and hobbies and their expectations and wishes during after final illness. It is possible to use all this information to develop the care plans so that they are more person centred than previously. The residents or their representatives had been involved in reviewing the care plans that had been drawn up by staff using the information they had gathered to meet resident’s needs and expectations. Visits by doctors and district nurses and GP appointments had been recorded. Residents said that they were assisted to attend the local hospital and visits to the GP or nurse. At their induction staff had been given training on how to work sensitively with residents who were in the final stages of their life and how to provide support Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 10 for relatives and other residents who might be affected by the death. The manager said that they would do everything possible to respect the wishes of residents if they wanted to remain in the home during their final illness. She said “Each case would be assessed and reviewed by a multidisciplinary team involving the resident and their family to look at the care plan and meet changes in individual care needs.” Staff said they were able to support each other to cope with their grief and if necessary counselling services would be arranged. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 11 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, 14, 15 This home encourages residents to be involved in making the decisions that affect their daily lifestyle. EVIDENCE: Records showed that residents meet together regularly to talk about what should be done to improve the quality of their life in the home. Some residents had said that the dining room was “dingy” and needed to be “smartened up.” As a result the dining room has been upgraded with lighter paintwork, new carpets, improved lighting and seating arrangements to make it feel lighter and more homely. The residents have also discussed menu choices and agreed that they preferred a set menu at lunchtime (with alternatives for anyone who requested them) and a greater choice at teatime. This suggestion has been implemented to everyone’s satisfaction. Now they are looking forward to being involved in planning the new menus for the summer. The manager has implemented the recommendation made at the previous inspection to seek the views of residents who may be reluctant to make comments in public. The home’s trainee carer meets with each resident weekly to find out if they have any comments to make about the service they receive. Improvements have been made already as a direct result of this work. For example some residents had commented on the routine for Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 12 breakfast and they said the changes that had been introduced were a big improvement. A member of staff has been given additional responsibilities to organise activities in the home and a weekly calendar of events was on display as a reminder for the residents, visitors and staff. A number of social occasions have been planned for the future months and residents said they were looking forward to them. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 Residents in this home are satisfied that their legal rights are protected and any complaint is taken seriously and acted upon. EVIDENCE: There had been no complaints since the previous inspection. The complaints procedure is written in large print for the benefit of residents who may have visual impairment and the home’s mission statement and statement of purpose reinforces the principle that comments and complaints will be taken seriously. People said that they knew what to do if they felt it necessary to make any comment or complaint. As stated previously a number of improvements had come about as the result of residents making their opinions known to senior staff. In addition the manager had introduced regular meetings between heads of departments to improve communication between staff in the home and to aid the implementation of any changes. The electoral register is kept up to date and residents who do not use the postal voting system are assisted to vote locally in political elections. Staff members were aware of an advocacy service that could approach to act on the behalf of residents who were unable to speak for themselves or who were without anyone willing to do so. The manager had experience of working with people who were subject to the Court of Protection. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 22, 23 The standard of environment in the home continues to improve and provides residents with comfortable and homely accommodation. Specialist equipment is available to enable residents to be as independent as possible. EVIDENCE: There has been significant financial investment to improve the accommodation and facilities in Holly Bank since Aegis took over the ownership of the home. The manager has undertaken an audit of the communal and private rooms used by the residents and works closely with the company’s estate manager to prioritise the work needed to refurbish the property. The rooms on the ground floor have been redecorated and fitted with new carpets and furniture. Previously there had been two adjacent lounges on the ground floor that had been connected by partition doors. The doors had been removed to create one large lounge area which the residents said was preferable, because there was more room to move around and the chairs could be set out in groups. Some bedrooms had benefited from refurbishment using good quality furnishings and fittings. The manager said that they were aiming to create a residential home with accommodation, food and services that were up to hotel standard. Staff Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 15 worked closely with occupational therapists and physiotherapists to assess the residents with mobility or bathing difficulties. Specialist equipment to help maintain independence had been provided where necessary. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 29 The home employs a skilled staff group who have been appointed following a robust and thorough recruitment procedure that ensures protection for people living and working there. EVIDENCE: Personnel files for new members of staff contained information about the checks carried out to ensure all staff members are suitable for their role. New members of staff were not allowed to commence work until the checks had been completed satisfactorily. On appointment they were involved in a thorough induction programme and were required to complete training in key areas to equip them with the necessary skills to carry out their work. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 17 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): 32, 34, 35, 37 The registered manager provides adequate direction, guidance and leadership for the staff so that residents are given consistent quality care. There are procedures and practices in place to protect the rights of the residents and to ensure the health and safety and wellbeing of the residents, staff and visitors. EVIDENCE: The manager is highly motivated and staff said that she was a good leader and role model. They respected her because, although she was their manager, she was prepared to work alongside them if necessary. On the day of the inspection she was working in the kitchen preparing the midday meal because the cook had rung in to say she was unwell. Her enthusiasm had encouraged them to improve their knowledge, skills and confidence to provide consistently good care to the residents. Since the last inspection the staffing structure had been changed with some staff having been promoted into more senior roles in recognition of their skills and expertise. The staff support structure, and the Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 18 commitment and professionalism of the staff team had helped them to achieve the Investors in People award. Many of the residents appreciated the time the manager regularly spent talking with them to make sure they were happy with the care and services they were receiving. Regular tests and checks were made of equipment and systems in the home and with record keeping to ensure the home is a safe place in which to live and work. Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 19 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 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X 3 3 3 3 X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 X 3 X Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holly Bank DS0000063598.V281030.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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