Inspection on 12/07/05 for Holly Bank House

This inspection was carried out on 12th July 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

Holly Bank House 13/01/09

Holly Bank House 01/05/07

Holly Bank House 21/08/06

Holly Bank House 10/01/06

Holly Bank House 08/03/05

Holly Bank House 21/06/04

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

CARE HOME ADULTS 18-65 Holly Bank House Coltham Road Short Heath Willenhall West Midlands. WV12 5QB Lead Inspector Maggie Bennett Announced 12 July 2005 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holly Bank House Address Coltham Road Short Heath Willenhall West Midlands. WV12 5QB 01922 710524 01922 493250 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Walsall MBC Mr. David Boyes Care Home 21 Category(ies) of Physical disability (21) registration, with number of places Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: Hollybank House is a single storey purpose built residential home located in the Short Heath area of Walsall. The home was commissioned in 1984 and is owned and managed by Walsall Metropolitan Borough Council. It provides accommodation for adults with physical disabilities and is suitably adapted to meet their needs. Hollybank is conveniently situated for the local shops, the health clinic and a public house. Service users are disappointed that the local Post Office has recently closed. The building is divided into three units, one of which is made up of seven self-contained bed-sits with bathroom and kitchen facilities. The remaining two units each have seven bedrooms with a shared sitting room, dining room and kitchen. Both units also have shared toilets, bathroom and shower facilities. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, carried out on a weekday, between the hours of 8.30 a.m. and 7.30 p.m. A pre inspection questionnaire was received from the home, as was anonymous feedback from service users and their relatives. Discussion took place with a number of service users on an individual basis, with two members of care staff and with the registered manager. A tour took place of the building. Various documents were inspected, including assessment information and care plans. What the service does well: What has improved since the last inspection? As noted above, care planning has improved considerably since the last inspection. The home now have Policy Guidance with regard to risk management. Staff now have an individual training and development assessment. Staffing ratios have also improved and a number of service users confirmed during the inspection that this has made a difference to their daily lives. There have been a number of improvements to the maintenance and décor of the home. New furniture has been purchased and service users are being consulted about what they would like in their rooms. The garden area is very much improved and is now a pleasant and accessible area. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 6 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. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 There are good assessment procedures in place, which ensure that the needs of people staying at Hollybank will be met. EVIDENCE: The assessment information for three service users on respite stays was seen at the inspection, in addition to the assessment of a newly arrived long stay service user. All service users had received the benefit of a proper assessment prior to their stay. Following assessment, the registered manager writes to the service user confirming that the home is able to meet their needs. Specific needs and how they will be addressed are included in the letter. Any nursing needs are arranged with the local District Nurses prior to admission. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 Care plans are clear and comprehensive, conveying a clear picture of service users’ assessed and changing needs. Service users are fully involved in their care planning and are supported to be as independent as possible, even though this may mean taking risks. EVIDENCE: Four care plans were inspected in detail. These demonstrated excellent care planning systems, which set out how current and anticipated specialist requirements are to be met. There is evidence that care plans are compiled and reviewed with the involvement of the service user. This was confirmed by service users during the inspection, all of those spoken to being well aware of their care plans. The care plans include an individual risk assessment. Although there was evidence that both care plans and risk assessments are reviewed, these reviews must be signed and dated. Service users spoken to confirmed that they were able to make choices about their daily lives and be as independent as possible. This may include taking risks. There is a Missing Person Procedure in place. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 15 and 17 Service users are enabled to get out and about in the local community and into nearby towns. The closing of the local Post Office is very much regretted. The involvement of family and friends is clearly encouraged, as long as the service user is in agreement. Some service users feel that the quality of the food has deteriorated with the change of suppliers and they are dissatisfied with the seemingly institutional and backward step of bulk buying in large containers, which they are unable to handle. EVIDENCE: Service users confirmed that they were able to access facilities in the community and generally used Ring and Ride or taxis for transport. Most were very disappointed that the local Post Office had recently closed. Both staff and service users showed that they are aware of rights of access to public facilities under the Disability Discrimination Act, although one service user said she had been unable to access her Bank recently. Community Wardens are now using Holly Bank as a base. Service users spoken to were pleased about this and did not see it as an infringement of their privacy. Those spoken to said that this had been a very positive step and that the congregating of young people outside the home had now stopped. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 11 The presence of the Wardens also gave the service users a greater feeling of security, particularly in the daytime. The home has been subject to a number of break-ins in the past. All service users are on the electoral register and are enabled to vote if they wish. One of the service users felt that the increase in staffing ratios had enabled her to get out a bit more. Service users confirmed that family and friends may visit at any time and that they can choose whom they see and when. Service users are offered a range of meals throughout the day and drinks and snacks are available at all times. There is a clear choice on the menu, one of which is vegetarian. All care plans contain a nutritional risk assessment and there is evidence that professional advice is sought when there are concerns about low weight or any eating or drinking disorders. Several of the service users spoken to expressed dissatisfaction with the current quality of the food. One service user felt that his cultural needs with regard to food were definitely not met and that there should be a greater selection of well cooked AfricanCaribbean food. This person said: “I’m not eating properly. I throw a lot away”. Other service users were concerned that the home’s supplier had recently been changed and that, as a result, the quality of the food was not as good as it had been. It was noted that there were far more processed meals on the menu than there had been in the past. Comments made by service users were that the orange juice supplied was “vile”, the cereals were no longer Kelloggs and did not taste so good and that bottles of pop and sauces were in large containers. One service user said: “We can’t pick them up.” Those service users who wish to are thus being denied their independence at mealtimes if they have to rely on staff pouring squash and putting sauce on their meals. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 Healthcare needs are well documented and are compiled with the individual service user. They give clear directions to ensure that service users’ healthcare needs are assessed, recognised and addressed. The systems for the administration of medication are good, with service users’ medication needs being met. Some improvements need to be made to the storage of medication. EVIDENCE: Healthcare needs are clearly documented in care plans and are compiled with the assistance of the service user. The home is proactive in obtaining the services of relevant healthcare professionals. All service users are supported when attending outpatient and other appointments. Care plans clearly indicate when advice and medical attention should be obtained for individual service users. Annual health checks are offered by two of the home’s G.P.s. Consent to medication has been obtained from all service users. Where possible, service users take charge of their own medication and all have a lockable facility in which to keep it. Excellent records are retained of all medicines received, administered and leaving the home. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 13 Some medicines, which are supplied in monitored dosage system containers, are currently kept in a filing cabinet and the home is requested to seek advice on whether such storage meets the requirements of the Royal Pharmaceutical Society, who state that “Adequate lockable storage must be provided at all times for medicines supplied in MDS containers.” Medicines must not be stored above 25 degrees. Controlled drugs must be stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. A separate, secure and dedicated refrigerator must be available in the home to be used exclusively for the storage of medicines requiring cold storage. The temperature of the medicines refrigerator should be monitored daily when in use, using a maximum/minimum thermometer and recorded. The home’s Pharmacist visits on a regular basis to carry out an audit of the medication. Staff who administer medication must receive accredited training. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 There is a clear complaints procedure in place and service users are informed of how and to whom to complain. EVIDENCE: The home use the Walsall MBC “Compliments, Comments and Complaints” procedure. Service users are aware of the procedure to follow should they wish to make a complaint. Clear records are maintained of any complaints. Records are also kept of any other issues raised by the service users, which do not constitute complaints. No complaints have been made since the last inspection. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26 and 27. The standard of décor within the home has improved and Holly Bank provides its service users with a comfortable environment. Service users in the bedsits, however, are unable to access the washing up area in the kitchenette and this is causing some frustration. EVIDENCE: Since the last inspection a number of improvements have taken place to the physical environment of the home. This includes work to the garden, which is now a pleasant area for service users. A planned programme for the renewal of the fabric and decoration of the home has been forwarded to the Commission. Holly Bank regularly admits people for respite care. These service users do not occupy separate premises, but benefits for both groups (long stay and respite) can be demonstrated by the home. There is access to local amenities. There have been some “break ins” recently and further fencing is to be erected to prevent prowlers entering the grounds. Service users’ rooms seen during the inspection were clean and in good order. Some need re-decorating, but this is in hand and new furniture has been purchased. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 16 A form has been devised with regard to Standard 26.2, which will ensure that service users are consulted about the furniture and fittings in their individual rooms. It is disappointing to note that the kitchenette areas in the bedsits have received no attention. This is particularly upsetting for one service user, who finds that trying to use the washing up area is very difficult and actually contributes to back pain. This service user said: “Why should I break my back because it’s not adapted for me?” It was noted that the floor covering in the shower in C area had been replaced. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 35. Although there are some shortfalls, staff are generally well trained and have a good understanding of the service users’ needs. The majority of service users feel well supported by an effective staff team, but the occasional arguing and gossiping among staff, reported by some service users, throws doubt upon their professionalism and whether all staff respect the fact that they are in someone else’s home. Staffing levels are now adequate and ensure that service users’ needs are met. EVIDENCE: At the last inspection the home were required to provide staff with training in Disability Awareness and Disability Equality. This training has still not taken place, but is being sought. Staff were observed to have a good understanding of the service users’ needs and those spoken to were committed and enthusiastic. The home have in excess of 50 of its staff trained to NVQ Level 2. The majority of the service users expressed satisfaction with the quality of care they received from the staff. One said that the staff were “very helpful”, while another said: “they will do anything for you”. Some service users, however, expressed disappointment at the attitude of a minority of the staff. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 18 One service user said that staff were heard arguing loudly in the staff room with the door open. Another person said that there was a lack of privacy as staff “talk about other staff in front of residents.” This has happened when staff are carrying out caring tasks. The service user said: “I hear them talking about other people and I wonder if they’re talking about me. I used to be gullible before I came here. I want to be able to trust people”. These issues must be addressed, as there appear to be a minority of staff who have poor attitudes and are not respecting the service users. Arguments and gossip have no place in the service users’ home. The ratios of care staff to service users has been improved and there are now sufficient staff on duty to meet the needs of the service users. Service users spoken to said that they had noticed an improvement in this area. Agency staff are used, but the home try to use the same agency staff who know the service users. Staff meetings take place regularly. Staff are recruited by Walsall MBC, who hold a number of records at the Civic Centre. All those records required by the Care Homes Regulations must be available in the home. There is evidence that Criminal Records Bureau checks and POVA checks are carried out before new staff are employed. Service users are not involved in staff selection, although this matter is currently being discussed with the Service Users’ Council. All staff have an individual Training Profile. In addition to NVQ and mandatory health and safety training, staff have also taken part in HIV Awareness Training, Falls Prevention training, Understanding of Parkinsons Disease and Adult Protection. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 The manager provides clear leadership and is well supported by senior staff. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager has been in post since 1983 and is very much liked and respected by both service users, staff and relatives. This is reflected in the responses to anonymous questionnaires sent to the Commission prior to the Inspection. The manager is about to complete the NVQ4 and Registered Managers’ Award and undertakes periodic training in order to update his skills and knowledge. A random inspection of staff files and observation of the home’s training plan, showed that the majority of staff have up to date training in first aid, fire safety awareness and food hygiene. Training in moving and handling has been arranged for September. This training does not, however, include training in the use of the hoist and this remains a requirement. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 20 Training in infection control and accredited medication training (see Standard 20 above) is also required for some staff. Evidence was seen of the regular testing of the fire alarm system and of fire drills. The testing of the emergency lighting system must be carried out on a monthly basis and recorded. Evidence was also seen of the regular testing and maintenance of equipment in the home. As stated in Standard 24, there have been concerns with the security of the premises. There are flood lights which light up the gardens and a further fence is to be erected. During the day-time the presence of the Community Wardens has helped service users to feel more secure. There are policy guidelines in place with regard to risk management. All new staff receive induction and foundation training to “Skills for Care” specifications. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 3 x x x Standard No 11 12 13 14 15 16 17 x x 3 x 3 x 2 Standard No 31 32 33 34 35 36 Score x 2 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Bank House Score x 4 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? 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 20 Regulation 13(2) Requirement Controlled drugs must be stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. A separate, secure and dedicated refrigerator must be available in the home to be used exclusively for the storage of medicines requiring cold storage. Staff who administer medication must receive accredited training. (This is currently being arranged). Service users with kitchenettes must be able to access the sink area. (Previous timescale of 30/06/05 not met). The incidents of staff arguing and gossiping must be addressed through staff meetings and in consultation with service users. All those staff records specified in Schedule 4 of the Care Homes Regulations must be available in the home. Service users must be actively supported to be involved in staff selection and be supported through the processes of joining and departure of staff. (This Timescale for action 31/08/05 2. 20 13(2) 31/08/05 3. 20 13(2) 31/08/05 4. 26 23(2)(f) 31/08/05 5. 32 12(1)(a) 31/08/05 6. 34 17(2) 30/09/05 7. 34 12(2) 31/10/05 Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 23 8. 9. 42 42 13(5) AND 18(1)(c) 23(4) issue is currently being discussed with the Service Users Council). (Previous timescale of 30/06/05 not met). Care staff must receive training 31/08/05 in the use of the hoist. (Previous timescale of 30/04/05 not met). Emergency lights must be tested 12/07/05 each month and the testing recorded. 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 6 20 37 Good Practice Recommendations It is recommended that reviews of care plans and risk assessments are signed and dated. It is recommended that the home seek advice with regard to the storage facilities for medication. It is recommended that the registered managers job description is updated to include all elements of Standard 37. Holly Bank House E55 S36419 Holly Bank House V231781 120705 MB Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA 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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