Inspection on 08/05/06 for Holly Bank

This inspection was carried out on 8th May 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 23/02/06

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 Jenny Donnelly Unannounced Inspection 8th May 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.V291179.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.V291179.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) Aegis Residential Care Homes Ltd Miss Ann Elizabeth Mason-Day Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Holly Bank DS0000063598.V291179.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. 23rd February 2006 Date of last inspection Brief Description of the Service: Holly Bank care home is situated on the promenade in the coastal village of Arnside and has views over Morecambe Bay to the Lakeland fells. The home provides personal care and support for up to 31 older people. 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; many 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. The weekly fees at the date of inspection ranged from £388.00 to £603.00 according to the standard of bedroom occupied. The homes’ statement of purpose, service user guide and last inspection report, could be seen at the home, or copies requested from the manager. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon. Neither the registered manager nor the home’s administrator was present at the time. The company’s marketing and operations manager, training manager, and a manager from another Aegis home were present. The inspection comprised of a tour of the building, talking with residents, and staff, and observation of meals and activities. Care and medication records were inspected. A further announced visit was made to Holly Bank on 23 May 2006 to inspect staff files and other confidential records, which could not be accessed in the manager’s absence. The inspector had received completed questionnaires from some residents about the home. What the service does well: What has improved since the last inspection? What they could do better: The new care planning system was complex and had not been fully completed by staff, to detail all residents care needs, risk assessments and wishes. The stock of controlled drugs was not regularly checked, and should be, especially those items not in regular use. The provision of meals was poor, in that residents did not have a choice of menu, and did not know in advance what was to be served. Main meals were Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 6 served on tea plates, which looked unattractive and were difficult for residents to manage without spilling. Requirements or recommendations are made on these items. 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. Holly Bank DS0000063598.V291179.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.V291179.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 and 3 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The home provided good information for prospective residents and their families. Pre admission assessments had been undertaken, to ensure that prospective residents’ needs would be met. Residents had been issued with a contract of residency. EVIDENCE: The home had produced a statement of purpose and service user guide, which served to inform prospective residents and their families about Holly Bank. These documents were on display in the entrance hall, and copies were available on request, along with the homes’ latest inspection report. The files of three residents were inspected and found to contain a signed copy of their terms and conditions of occupancy. These contracts were either directly between the resident and Holly Bank, or arranged through the County Council, depending on who was responsible for paying the fees. Fees were set according to the standard of bedroom occupied. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 9 There was a standard pre-admission assessment form, which was completed prior to any new resident being offered a place at Holly Bank. This ensured that the home would be able meet the persons’ needs, before they moved in. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. Residents felt they were very well cared for, although the homes’ care records lacked some detail on residents’ needs. Residents’ felt their privacy and dignity was respected by staff. The management of medicines was good, although stock checks of controlled drugs should by carried out. EVIDENCE: In February, the home introduced new care planning documentation, known as a Standex system. During the unannounced inspection visit, these were found to be incomplete and lacking in detail about residents’ needs. By the next visit, some work had been undertaken to improve the care plans, and provide more detail on individuals’ needs and wishes. This improvement work needs to continue to ensure that staff know exactly what support residents’ need. The manager was hoping that when she appointed a deputy, this new person would take the lead on care planning, and support staff in completing these quite complex documents. There were records of health care interventions, such as visits from the community nurse, doctor and chiropodist. Residents all appeared well cared for; groomed and nicely dressed in clean clothing. Residents said they could have a bath or shower at least weekly, and Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 11 felt the staff looked after them well. Residents felt staff maintained their privacy and dignity, and listened to them. However three residents had been named and their comments/concerns were on display with the homes’ quality assurance information. This is commented on further under the management section of this report, and a recommendation made. Inspection of the medicines, found these to be in good order. The local pharmacist supplied the medicines in pre-packed cassettes with printed administration records charts. There were some medicines, which could not be supplied in the cassettes, and these were supplied separately in bottles or packets. The medicines stock was tidy, with no evidence of overstocking, and the medicine records had been accurately completed. The home held some controlled drugs and kept accurate double-signed records of their use. There was no regular stock check of controlled drugs, which is recommended, especially for items not in regular use. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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 and 15 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. Residents enjoyed a good and varied programme of social activities and events, and were enabled to maintain close links with their friends and family. Residents were able to exercise choice and control over most aspects of their daily life. The choice and presentation of meals was poor, and needs to be improved, to enhance residents anticipation and enjoyment of meal times. EVIDENCE: The home advertised activities and events, through monthly and weekly planners, which were sited around the home, and through the homes’ newsletters issued to each resident. The organised events for May were a cheese and wine evening, a communion service, and visits by church singers and another entertainer. The in-house activities for the week comprised of an advertised daily event including a walk along the promenade, a baking session, bingo, a film and the hairdressers visit. The baking session took place after lunch on the day inspection, and comprised of making chocolate crispy cakes, which were served with afternoon tea. The residents’ that took part in this said they enjoyed the activity and were pleased to have produced something for other residents to enjoy. Some other residents commented that they were not sure what activities were on offer. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 13 Holly Bank operated an open visiting policy, with any restrictions on visiting made only according to residents’ wishes. Residents felt the daily routine within the home was fairly flexible, and allowed them to state their preference in relation to bed times and rising times. Those residents’, who wished and were able, managed their own affairs, although most received assistance with this from family and friends. The home had information available on how to access a local advocacy service for independent advice and support The quality and choice of meals generated a very mixed response from residents. Whilst some residents said they enjoyed the meals, saying “it’s good plain cooking”, “the meals are fine” and “the food is nice”. Others said “we could do with a change of menu”, “the meals are usually uninspiring” and “tea is a very poor meal”. The inspector observed that there was no choice on the menu, which showed one lunch dish only. The days’ menu was not on display except for in the kitchen. Residents did not know what was for lunch until it was placed infront of them at the table. Although one resident was offered a choice of dessert, as staff knew that person did not like semolina, no other resident was offered a choice. The presentation of the meal was poor, in that a full meat, potatoe and vegetable meal was served on tea plates. This not only looked unsatisfactory but was difficult for people to eat, without the food spilling off the plate. In response to these issues, the inspector was told that new dinner plates had been ordered, and a new menu was being devised. It is required that the choice and presentation of meals be improved to enhance residents enjoyment and anticipation of meal times. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. There were sound sysytems in place for residents to raise any concerns or complaints and be listened to. Staff were aware of their duty to protect residents. EVIDENCE: The home had a complaints procedure instructing people how and who to make any complaint to. Residents said they knew how to complain, but had not needed to do so. No complaints had been made to the home or to the inspector since the last inspection. Staff had received training in the protection of vulnerable adults (abuse) and the home had procedures in place for reporting any suspicion or allegations of abuse to the appropriate authorities. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The home provides a pleasant, clean and safe environment for residents to live in. There was plenty of light and spacious communal rooms, and bedrooms were individual and homely. There was an refurbishment programme in place, to upgrade all areas of the buidling. EVIDENCE: Holly Bank is situated on the promenade in Arnside, and enjoys open views over the Kent estuary and Lakeland fells. The home is within walking distance of the local shops and public transport routes. The building is two converted and extended Victorian town houses. Since Aegis purchased Holly Bank just over a year ago, much redecoration work had taken place. The lounges and conservatory had been redecorated with new carpets provided throughout, and a new large screen television had been provided for one lounge. The dining room had been decorated, and further plans were being discussed for improving this area. A drinks Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 16 dispensing machine had been provided in the foyer for visitors. A new hairdressing salon with professional fittings had been provided. Bedrooms had been, or were going to be, upgraded. Some bedrooms had been upgraded with new carpets and decoration, whilst others had been fully refurbished with new en-suites and new furniture fitted. This work was ongoing and two bedrooms were out of use at the time of the visit. The bedrooms seen had been personalised by the addition of residents’ personal possessions including some items of furniture. Bedrooms appeared homely and individual to the occupant. The kitchen had several access doors, which promoted general thoroughfare by staff. The company had reduced this unnecessary traffic through the kitchen and were contemplating a re-design of the area. The laundry was also accessed via the kitchen, or from the back stairs. To prevent dirty laundry being taken through the kitchen, all laundry had to be taken upstairs, along the corridor and down the back stairs. Whilst being inconvenient, this did reduce possible spread of infection. The laundry was well equipped, but had no dedicated laundry staff, and was sited well away from resident areas of the home. The manager should monitor the use of care staff for laundry duties, especially as the homes’ occupancy increases. The home was generally clean and tidy throughout, and residents confirmed this was always the case. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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 and 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The home was staffed appropriately to meet residents’ needs. Recruitment procedures were sound, and staff received appropriate training to do their jobs well. EVIDENCE: Staffing levels comprised of four carers during the day, reducing to three carers at 4pm, and two during the night. Staff felt these arrangements were satisfactory as some residents were quite independant. There were 23, then 21 residents in occupancy at the time of the inspection visits. The homes total occupancy is 31, and staffing levels will need to be revised when the home has more residents. There was also kitchen, domestic, administrative and maintenance staff. A keyworker system had been commenced in April, whereby each carer took a particular interest in the care of a small group of residents. This new system was not fully operational as yet. The home had a vacancy for a deputy manager, and interviews for this were about to take place. At the time of the first inspection visit, there was no staff rota for the following week, although this had been rectified by the second visit. Staff files were inspected and found to be complete in respect of recruitment and training records. Supervision records demonostrated that staff had individual meetings with the manager to discuss their work and training needs. Training records showed that training in first aid, food hygeine, fire safety, moving and handling, and abuse had taken place. Two of the care staff had Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 18 completed an NVQ in care, and five staff were in the process of completing an NVQ. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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, 36 and 38 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The manager was suitably qualified and competent to run the home, and there were systems in place to ask residents their views about the service. Arrangments to protect the health and safety of residents and staff were in order. EVIDENCE: The manager was suitably qualified and competent to run the home, and was well supported by Aegis senior managers. Aegis undertook annual surveys of residents, as part of their quality assurance work. This survey was last conducted at the end of 2005, and the results from the survey rated the home as good or very good, with just one poor rating. The results of the survey had been collated at the Aegis head office and a laminated copy supplied to the home for display. Unfortunately individual comments/concerns by three named residents had been included on this, and were on display. This Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 20 information should not form part of a public display, but needs to be provided in confidence to the manager for her to follow up. The home did not manage any money on behalf of residents. There was a safe should anyone wish to deposit an item for safekeeping. The health, safety and welfare of residents and staff were given a high priority. The homes’ maintenance man ensured all regular servicing and maintenance checks were carried out. Maintenance records were good, and staff had received instruction in fire safety and in the safe moving and handling of residents. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 22 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. 1 Standard OP7 Regulation 15 Requirement Care plans must set out in detail all the actions required by staff to meet the persons’ health, personal and social care needs. Residents must be offered a choice of meals, and meals must be presented in an appealing manner. Timescale for action 01/09/06 2 OP15 16 01/09/06 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 2 3 Refer to Standard OP9 OP27 OP9 Good Practice Recommendations Regular stock checks of the controlled drugs should be carried out. The manager should monitor the laundry demands on care staff as occupancy increases, and consider providing dedicated laundry hours. Information on public display should not include names and comments made by residents, without their express permission. Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Holly Bank DS0000063598.V291179.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!