Inspection on 21/08/06 for Holly Bank House

This inspection was carried out on 21st August 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Bank House 13/01/09

Holly Bank House 01/05/07

Holly Bank House 10/01/06

Holly Bank House 12/07/05

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 Key Unannounced Inspection 21st August 2006 09:35 Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 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 House DS0000036419.V309817.R01.S.doc Version 5.2 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 Adults 18-65. 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 House DS0000036419.V309817.R01.S.doc Version 5.2 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 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) Walsall Metropolitan Borough Council Care Home 21 Category(ies) of Physical disability (21) registration, with number of places Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 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. 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. The charges at the home are £738.00 per week. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a weekday between 9.35 a.m. and 8.45 p.m. Prior to the inspection the home had forwarded to the Commission a Pre Inspection Questionnaire. Eleven service users completed Satisfaction Surveys, which were also returned before the inspection. During the course of the day six service users were spoken to. Discussion also took place with staff members and the new Manager of Hollybank. The care plans of 4 service users were seen and their care was “case tracked”. The medication and administration records were seen. Several staff files were seen in order to check recruitment practices and training records. Various other documents were inspected to verify that health and safety checks are carried out. A tour took place of all the communal areas of the building and garden. In addition some bedrooms were seen. All the key standards of the National Minimum Standards were inspected at this visit. At the last inspection of Hollybank a total of 7 statutory requirements were made. It was found that 5 of those requirements had either been met or were in the process of being met. 5 further requirements were made on this occasion. A new Manager was appointed to the home in July 2006. The Manager is working closely with service users and staff. There will be changes and the signs are that service users and staff have acknowledged this and, although there is some anxiety, they are looking forward to the future. What the service does well: There are many areas of good practice at Hollybank. Assessment procedures are sound and ensure that no one is admitted until their needs have been properly assessed and they have been given an opportunity to look around the home. Care planning is generally of good quality. The home are, however, looking are ways of improving this still further and the proposed new format should make care plans more accessible and provide a clearer picture of each person’s individual needs. Full advantage is taken of local Day Centre and Colleges. Independence is encouraged and privacy respected. Healthcare needs are well met and there is good liaison with local healthcare professionals. There are sound procedures in place to address any complaints and staff have a good understanding of their responsibilities with regard to the Protection of Vulnerable Adults. There are good standards of cleanliness in the home. The majority of service users feel that they are well cared for by the staff and a cheerful and friendly rapport was observed between service users and staff during the inspection. 70 of staff are trained to NVQ level 2 or above. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some care plans had not been reviewed for a considerable period. Several risk assessments were found to be well out of date. It is acknowledged that the management of the home are aware of this and have already taken steps to ensure that regular reviews take place and that care plans are updated to reflect any changes. There is no private sitting area at Hollybank and it is suggested that service users are asked how they would like the communal rooms (such as the old hairdressing room) to be utilised. Some service users are still unhappy about the food served at Hollybank and more consultation needs to take place with individuals about their likes and dislikes. The building presents as tired and outdated and refurbishment and repair is needed in several areas. Bathrooms and toilets are particularly uninviting. There has recently been a problem with the supply of hot water to some rooms. Several of the new doors cannot be opened by service users and this is being addressed. There are concerns that the large glass area in the foyer of the home could be hazardous. Care needs to be taken with the way that the promotion of independence is communicated to service users. During the inspection there was mention of a “bad attitude” from some staff who are alleged to have said things like “do it yourself” when a request for assistance has been made. The home must ensure that all those staff records required by Regulation are available on the premises (or that there is written verification of satisfactory checks from the Responsible Persons). Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 7 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 DS0000036419.V309817.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 2 The overall outcome for this group of Standards is judged to be Good. No prospective service user is admitted to the home until their needs have been properly assessed. Service users are fully involved in the assessment process and are given the opportunity to meet staff and look around the home before making any decisions. EVIDENCE: One new service user has been admitted to the home on a permanent basis since the last inspection. The assessment information for this person and for that of a service user on a respite stay was seen at the inspection. Both service users had been referred through Care Management and both had had an up to date assessment of their needs. This included an up to date risk assessment. The assessment takes family/carers’ needs into account. This assessment information has been used to develop the care plan (see Standard 6). From discussion with Manager, it is clear that the home have been fully involved in decisions with the referring social worker as to whether the home will be able to meet the individual service user’s needs. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 6, 7 and 9. The overall outcome for this group of Standards is judged to be Adequate. The home are currently in the process of changing the format of the Care Plans. Although they were good in the past, the new format should make them more accessible and provide a clearer picture of the person’s needs. Work has already commenced on ensuring that care plans are regularly reviewed and updated to reflect changing needs. Some service users have not had the benefit of a review for a considerable time. Service users confirm that they are able to make decisions about their day-to-day lives. Risk is assessed, although some risk assessments are badly in need of review. EVIDENCE: At the announced inspection of Hollybank in July 2005 Care Plans were found to be in good order and several of the service users spoken to were aware of the content of their care plans. Care plans were not inspected at the unannounced inspection in January 2006. The Manager and staff at Hollybank are currently in the process of changing the format of the care plans and therefore not all of those seen were in the up to date format. The care plan of a newly arrived service user and those of 2 Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 11 service users who have lived at Hollybank for some years were seen at the inspection. The new format was seen in two of these plans. The Action/Support plan is generated from the single care management assessment and the home’s own assessment. It sets out how current needs will be met and is divided into different aspects of the person’s life. Each individual profile will contain a risk assessment. This has been done for the newly arrived service user and is gradually being introduced for all service users. It is also intended that the care plans for service users on respite stays will contain the same amount of detail as those who live permanently at Hollybank. One of the care plans seen gave details with regard to a restriction on choice. A further care plan was seen of a service user who had lived at the home since 1987. The care plan was dated 7.11.2004. and the last recorded review was 10.07.2005. The last recorded risk assessment was 18.07.2003. This is poor. The home must ensure that care plans are regularly reviewed and updated to reflect current needs. The Manager intends to introduce informal reviews with service users on a monthly basis. He is aware that six monthly formal reviews have not been taking place on a regular basis for all service users. The home have been in touch with the Social Work Team responsible for this, requesting that these reviews are arranged as a matter of urgency. The Manager states that 2 members of staff have been identified to review all risk assessments and to ensure that up to date risk assessments are available in all case files. It is recommended that there should be more detail in the plans of management guidelines for staff with regard to individual service users. This should provide information to staff on agreed actions in particular circumstances, in order to promote consistency. At present there is a key worker system in place. This is to continue, but the Manager intends to additionally introduce “one to one” sessions for service users with different members of staff to look at social support issues (see Standard 12). Service users spoken to during the inspection confirmed that they were able to make decisions about their day-to-day lives. 11 service users completed a questionnaire prior to the inspection and all 11 unanimously agreed that they were able to make their own decisions about what they did each day. Service users spoke about the different activities they took part in and made it clear that it was very much up to them what they decided to do. Service users take charge of their own finances. If there are limitations on choice, these are recorded in care plans. An example of this is where a service user is felt to be at risk if using an electric wheelchair outside the home. This is recorded and a Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 12 risk assessment is in place. The service user stated at the inspection why she was unable to use the wheelchair outside. As stated earlier, service users are able to take risks based on a risk assessment. There is a Missing Person Procedure in place at the home. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 12, 13, 15, 16 and 17. The overall outcome for this group of Standards is judged to be Adequate; There are opportunities locally for service users to attend Day Centres and College courses. All service users are on the electoral register and enabled to vote if they wish. Opportunities to fulfil personal aspirations are to be further encouraged at Hollybank with the introduction of more “one to one” time with staff and a more flexible rota, which will enable staff to accompany individuals on activities of their choice. Family and friends are welcome at Hollybank, but the lack of a private sitting room is a disadvantage and this should be addressed. Independence is encouraged and privacy respected. Generally the food is of good quality and recent difficulties should soon be resolved. More consultation should take place with service users about cultural needs with regard to food. EVIDENCE: Service users have opportunities to go to Day Centres or Colleges in the local community. One person had just enrolled for an art and poetry class at College, whilst another was attending a regular dancing class. A number of service users returned from the Day Centre during the inspection. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 14 Service users use the local shops, although the closure of the nearby Post Office was a disappointment to many. All service users are on the electoral register. One service user confirmed that she would be enabled to vote if she wished to, although had chosen not to. Staff time with service users outside of the home is regarded as part of their normal duties and recent changes in the rota have made this more possible. The present Manager is arranging for staff to spend more “one to one” time with service users discussing their aspirations with regard to outside activities and service users are being encouraged to make their own arrangements for these activities, with assistance, if needed, from a member of staff. The Responsible Persons provide each individual with a sum of money towards an annual holiday. Service users are able to use this in a number of ways – some choose to save the money for a long haul trip or more expensive holiday, some have an annual week’s holiday, while others use the money for a series of day trips. Service users confirm that their friends and family are able to visit at any reasonable time. Service users are able to entertain their visitors in their rooms, although some rooms are small and there is no private sitting room within the home. It is recommended that one of the several unused rooms in the home be converted into a sitting room for private visits. All service users have keys to their individual rooms. Service users spoken to during the inspection confirmed that their privacy was respected at Hollybank. It was observed that staff always knock before entering individual rooms. Service users have “pigeon holes” in which their mail is delivered. There is unrestricted access to the communal areas of the home. There are no rotas in terms of housekeeping tasks, but service users are requested to assist with clearing tables, washing and drying up, etc. Any rules on smoking, alcohol and drugs are stated in the contract. Menus seen show that a variety of foods are offered and that there is a choice available for each meal. Service users can choose where to eat their meals and during the inspection some chose to eat together, while others ate in their rooms. There were mixed feelings about the quality of the food at Hollybank at the moment. One person, who is a vegetarian, said that he was very satisfied with his meals. Another person would like to see more curries on the menu. He said that this only happened about once a week at present, but that when a curry was served recently it was “brilliant”. There were some concerns that one of the present cooks did not always seem to remember what had been requested. Some service users said that they had ordered a particular meal, but were then served with something else. The kitchen was seen during the inspection and was found to be clean and in good order. There were plentiful supplies of food. The cook confirmed that Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 15 fresh vegetables and fruit were supplied on a regular basis. The temperature of the cooked foods is taken and records were seen to verify this. There is evidence that fridge and freezer temperatures are taken, but the records for the day of the inspection could not be found. Service users’ nutritional needs were noted in some of the Care Plans seen. Not all of the nutritional screening tools on individual files, however, were up to date. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 18, 19 and 20. The overall outcome for this group of Standards is judged to be Good. Service users feel that they are assisted in ways which meet their needs. The promotion of independence and autonomy is of high priority to the new manager and some service users are looking forward to experiencing greater innovation in this area. Healthcare needs are detailed in service user plans and there is good liaison with local healthcare professionals. Medication is correctly stored and administered. All staff are about to commence ASET training in the Safe Handling of Medicines. EVIDENCE: Service users spoken to during the inspection said that they were assisted in ways which suited their needs. All personal support is provided in private. Times for getting up, going to bed and other daily routines are chosen by the individual service users. The Manager intends to consult with service users about the staff that work with them and to meet their needs and wishes as far as possible. It is not always possible for care to be provided by a person of the same gender. Various items of equipment are provided in the home to assist service users to be as independent as possible. The enabling of independence is of high priority to the present Manager and this has been communicated to the service users. Some feel very positive about this. One person said that this was “exciting” and welcomed the opportunity to take a Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 17 fresh look at the way things were done in the home. Another person also welcomed this and gave an example of how she spoke with Wheelchair Services herself when negotiating for a new wheelchair. One person, however, was not so happy with the concept of “increased” independence. This person felt that they made sure they were always as independent as possible and when they requested help, it was because they needed it, not because they were abdicating their independence. As stated earlier, the key worker system will continue at Hollybank, but all staff will be expected to have “one to one” time with service users and to consult with them about ways of enhancing their independence skills. Service users are registered with a local G.P. and use NHS services in the community. They are also given opportunities to attend for routine screening. The home have recently developed a comprehensive Medication Policy and Procedure. Service users’ consent to taking medication prescribed by their G.P. obtained and their written consent recorded in individual care plans. Some service users choose to take charge of their own medication and have a lockable facility in their rooms for this purpose. A check was made of a random sample of the current medication and accompanying records and all were in order. Controlled drugs are stored, administered and recorded appropriately. It is the home’s policy for 1 member of staff to administer the medication and for a second to witness the administration. Staff are about to commence the Safe Handling of Medicines Aset training in the near future. They have also received training from the home’s Pharmacist. The Commission’s Pharmacy Inspector has visited the home and provided them with information and advice. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 22 and 23. The overall outcome for this group of Standards is judged to be Adequate. There are sound policies and procedures in place with regard to Complaints Procedures and the Protection of Vulnerable Adults. The majority of service users feel that their concerns are listened to and acted upon. EVIDENCE: The majority of service users spoken to said that they would know who to speak to if they wished to make a complaint and they also felt that they would be listened to. In the 11 returned surveys, 11 said that they would know who to speak to if they wished to make a complaint and 10 said they would know how to make a complaint. Asked if staff listened to them and acted on what they said, 6 said “always”, 2 said “usually” and 3 said “sometimes”. This seems to show that although the majority of service users spoken to said they were happy that they were listened to, there are some who may not be as satisfied as others and are not expressing this. When the new system is in place for more “one to one” interaction, this should help those service users who are less confident to express any dissatisfaction or unease they may have. One of the people who said “sometimes” added “key workers always listen”. One service user has made a complaint to the Commission since the last inspection. Although not fully resolved to the service user’s satisfaction, the home has continued in discussions and plans with the service user and the perceived problems are being addressed. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 19 The home have recently ordered new complaints leaflets from the Social Services. In addition to recording complaints, the home have a “concerns” book, in which service users and relatives can voice “concerns and grumbles.” Staff have taken part in Adult Protection training. There is a copy of the Walsall Social Services Adult Protection Policy in place and an updated version of this will be available from October 2006. The home is recommended to develop its own Policy and Procedure, which is in line with the Walsall document. There have been no allegations of abuse made at the home. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 20 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 the following standard(s): 24, 27 and 30. The overall outcome for this group of Standards is judged to be Adequate. The building is tired and outdated and needs refurbishment in several areas. Where refurbishment has taken place (particularly in some of the bed-sits) this has been of benefit to the service users. There are good standards of cleanliness and hygiene in the home, although recently there have been problems with the hot water supply. EVIDENCE: Hollybank is now 22 years old and the building does not meet modern day standards. 14 of the 21 rooms do not have an en suite facility and do not meet today’s space requirements of 15 sq. metres. There are no separate premises for short stay service users, but several stay at Hollybank on a regular basis and know the other service users well. On the day of the inspection the home was clean and free of any offensive odours. Service users, in their returned questionnaires, confirmed that this was usually the case. The premises are generally safe (apart from some areas in the garden, which slope suddenly), but many areas of the building are in need of extensive refurbishment and redecoration. All the bathrooms are drab and uninviting. Some bedrooms have been redecorated, but many are badly in need of some attention. There is a lot of wheelchair damage around the Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 21 building, which is inevitable, but some of the damage to corridors, doors and bedroom walls is making the building look run down. There is a planned programme of redecoration and maintenance and it is hoped that many of these issues will be addressed in order to make the home a more attractive place for people to live. The requirements of the Fire Officer have not all been met, but a rolling programme has been agreed and some areas have already been dealt with. The home is to have new optical smoke alarms fitted. One service user was concerned about the adaptor she was using for numerous electrical appliances. It is recommended that when the Fire Officer visits (this is being arranged by the home), his advice be sought on this. Since the last inspection the kitchenette areas of some of the bedsits have been refurbished. This has been welcomed by the service users in these rooms, particularly as they are now able to get close to the sink in order to wash up. New windows and doors have been fitted in several areas of the home. This is an improvement, but some of the doors have unsuitable locks and service users are unable to open them. The front door and doors to the garden also have unsuitable locks and handles. All these areas are to be addressed in the near future. It is strongly recommended that attention be given to the glass area in the front porch and reception area. This needs to be reinforced, as there could be wheelchair accidents or falls in these areas and service users’ health and safety must be protected. Carpets in the corridors of C Block have been damaged by bleach and need to be replaced. There are some rooms at Hollybank, which are currently unused (including the hairdressing room and old sleeping in room). It is strongly recommended that service users are consulted and that these rooms be refurbished and put to use in ways the service users would find appropriate. Apart from the pond area, which is attractive, the remainder of the garden is looking run down, particularly the old greenhouse area. As stated above, the building was clean and free of any offensive odours on the day of the inspection. There is a large laundry with washable flooring. The washing machines do not have a sluice facility. The home has policies and procedures in place with regard to the control of infection and staff are about to commence Infection Control training. It is strongly recommended that the home obtain a sluicing disinfector for the commode pots. The home have recently experienced problems with the water system and investigations are currently taking place to see how this can be resolved. The Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 22 Responsible Persons must inform the Commission of the date they expect this work to have been satisfactorily completed. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 23 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 32, 34 and 35 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 and 35. The overall outcome for this group of Standards is judged to be Adequate. Staff at Hollybank are cheerful and committed and service users generally feel that they are well cared for. There has been an improvement in the numbers of staff on duty and this is of benefit to the service users. The planned introduction of more “one to one” time will improve the service users’ opportunities to express their views of the home, the changes they would like to see and their own individual aspirations. Not all service users are happy with the “attitude” of some staff, particularly around issues of how enabling independence is presented. There are sound recruitment procedures in place, but the home must ensure that all those records required by Regulation are either available in the home or that there is evidence that they are available at the Headquarters of the Responsible Persons. Regular supervision is now taking place. EVIDENCE: The files of 3 recently appointed staff were seen in order to check recruitment practices. All files contained copies of 2 written references. Application forms are held at Social Services Headquarters in Walsall. Files seen also contained evidence of a satisfactory Criminal Records Bureau and Protection of Vulnerable Adults check. One of the CRB checks, however, was requested for a previous employer. CRBs are not portable and an up to date one must be obtained for this person. Not all files contained a copy of the person’s birth certificate. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 24 Service users meet prospective staff, but are not directly involved in the interview process. All staff are given copies of the statements of their terms and conditions. There are no volunteers working at Hollybank. There is a staff training plan in place. On all the files of the newly appointed staff there is evidence that they have completed induction training to Skills for Care specifications. The staff have taken part in Disability Awareness Training. One of the managers at the home is developing a training matrix and it is intended that as much training as possible should take place in house. Staff files show that the majority of staff have been successful in NVQ training. Training with regard to health and safety issues is covered in Standard 42. Staff rotas have recently been changed and staff have played an active role in developing the new rotas. This has resulted in better cover. In addition, 4 new posts have been created. There are now usually 4 support staff on duty during the daytime, plus a Manager. At night there are 2 waking members of staff. These staffing levels are an improvement on those noted at the last inspection. Staff spoken to were cheerful and pleased with the way things were going at the home. One spoke of the new Manager as being a “a breath of fresh air”. Another said that staff were being presented with more responsibilities and more challenges and were being requested to reflect on their practice and look at more innovative ways of assisting service users. A member of staff was writing a risk assessment during the inspection. She said it was the first time she had been asked to do something like this. The majority of service users spoken to said that they were happy with the way they were cared for by the staff. One person, however, felt that some staff still had an “attitude” and that the need to assist people to be as independent as possible may be being misinterpreted by some. This person felt that they were very independent already and that they only asked for help when they needed it. This person said that on occasions when help had been requested they had been told “do it yourself”. The person said: “I’m doing my best”. One mentioned that new staff who had recently been appointed were “brilliant”. One person felt that having 2 people looking after medication had depleted the staff group at that time. The manager did point out, however, that there were now always 4 carers on duty during these times, so there was sufficient cover. One service user felt that there were too many managers in the office and not enough support staff. In their returned surveys, 4 service users said that staff “always” treated them well, 2 said “usually” and 1 said “sometimes”. Although not specifically inspected on this occasion, there was evidence from staff files that staff are now receiving regular supervision. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 25 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The overall outcome for this group of Standards is judged to be Adequate. Hollybank has a new Manager who is working closely with service users and staff. There will be changes and the signs are that service users and staff have taken this on board and, although there is some natural anxiety, are looking forward to the future with confidence. There are systems already in place to obtain the views of service users and their representatives, but these are to be developed further. The health, safety and welfare of the service users and staff are promoted by the home’s policies and procedures. Training in mandatory health and safety areas, particularly fire safety, is still needed for several staff. EVIDENCE: The Registered Persons have recently appointed a new Manager to Hollybank, who has considerable experience in the caring profession. This person will shortly be submitting their application to become the Registered Manager of Hollybank to the Commission. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 26 Although not inspected in detail, from discussions with the Manager, service users and staff it is clear that the home can anticipate changes, which will encourage innovation and greater independence for service users. So far, these plans have been communicated in an open and transparent way. One service user described the prospects as “exciting”. Service users and their representatives are sent questionnaires requesting their views of the home. The new manager intends to further develop the way the home obtains customer feedback, particularly in relation to appropriate formats. He also hopes to set up Carers Meetings. As has been mentioned earlier, there will be more “one to one” sessions with service users to obtain their views. The home have recently elected their new Committee, who were due to have their first meeting on 23rd August. It is intended that the home will use the Walsall Social Services Older Peoples Homes Quality Assurance System as a basis for a similar system at Hollybank. From the staff files seen and from the home’s list of training undertaken, it can be seen that staff have taken part in Moving and Handling, Hoisting, Emergency Aid and Food Hygiene. Several are shortly to be participating in Infection Control training. There are some gaps in training among more newly arrived staff, but this should be covered when a new Training Matrix is introduced and training organised “in house”. Fire safety training has not been taking place at the required intervals. The Manager intends to attend the managers’ training run by the West Midlands Fire Service and will cascade this training to the staff. Records seen show that fire alarm tests take place each week, emergency lighting tests each month and fire drills at least every six months. Certificates were seen to verify that the fire fighting equipment and fire extinguishers were serviced in 2006. A gas safety check took place in February 2006. There is a 5 year electrical certificate (from 2004) in place. The hoists were serviced in August 2006. The water system was checked for legionella and the system disinfected in 2006. The home have been experiencing some difficulties with the water supply, but this is currently being dealt with. There are risk assessments in place with regard to safe working practice topics. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 27 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15(1)(b) Requirement Service users’ plans must be regularly reviewed. Risk assessments must be regularly reviewed. Care plans must be updated to reflect changing needs. Service users nutritional needs and likes and dislikes must be recorded in their care plans. Nutritional screening tools on care plans must be completed. An audit must be carried out of all bedrooms and those in need of repair and redecoration must be attended to. Damage to skirting boards, doors and walls must be repaired and redecorated. Damaged carpets in corridors must be replaced. All parts of the home to which service users have access must, so far as reasonably practicable, be free from hazards to their safety. Timescale for action 30/09/06 2. YA17 Schedule 3-o 30/09/06 3. YA26 23(2)(b) 31/10/06 4. YA24 13(4)(a) 31/10/06 Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 29 Service users must be able to open the doors to their rooms. The glass area in the front entrance at floor level must be reinforced in order to protect service users. All service users must have a 31/08/06 reliable supply of hot water. The Responsible Persons must inform the Commission of the date they expect the work on the water system to have been satisfactorily completed. Staff files must contain all those 30/08/06 documents required by Regulation. All staff must have an up to date Criminal Records Bureau check requested by the employer. CRB checks are not portable. 5. YA30 23(2)(j) 6. YA34 19 Schedule 4.6 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 YA6 Good Practice Recommendations It is recommended that care plans contain management guidelines for staff with regard to individual service users. This should provide information to staff on agreed actions in particular circumstances, in order to promote consistency. It is recommended that consideration be given to converting one of the unused rooms in the home into a private meeting area for service users’ visitors. It is recommended that Hollybank produce their own Adult Protection Procedure, which is in line with the local Social Services Procedure and the Department of Health document, No Secrets. It is recommended that bathrooms and toilets be updated and refurbished. They are currently drab and uninviting. DS0000036419.V309817.R01.S.doc Version 5.2 Page 30 2 YA24 3. YA23 4. YA27 Holly Bank House 5. 6. YA24 YA30 It is recommended that advice be sought from the Fire Officer with the regard to the use of electrical adaptors in service users’ rooms. It is recommended that the home purchase a sluicing disinfector for the commode pots. Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands 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. Extracts may not be used or reproduced without the express permission of CSCI Holly Bank House DS0000036419.V309817.R01.S.doc Version 5.2 Page 32 - 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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