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Inspection on 29/08/07 for Holly Hall House

Also see our care home review for Holly Hall House for more information

This inspection was carried out on 29th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The atmosphere of the home is warm and welcoming. It has a strong ` homely` feel. The staff, are friendly and polite and respond well to the residents` in their care. As with other inspections we observed residents` being confident to approach staff with requests, questions or just for a talk. Residents in general get on well. There was continual, friendly conversation between them throughout the day. Residents were all dressed appropriately. They purchase and choose their own clothes and hairstyles. Opportunities are open to all residents to access educational input and other resources within the community. All residents have very active leisure times. Trips, outings and holidays are offered on a very regular basis. The home has it`s own transport which allows regular outings and access to the wider community. The premises are well maintained. Furniture, fixtures and fittings are all domestic in style. Resident bedrooms are all personalised with their own belongings. Residents` are encouraged to maintain contact with family and friends. Residents` spoken to confirmed that they like the home and living there.

What has improved since the last inspection?

Risk assessment processes have been reviewed which increases resident safety. There is now a senior or manager on each shift including weekends. Pictorial menus have been produced and are available within the home to aid resident understanding. 50% of the care staff team now have NVQ level 2 or above. Which means half of the care staff team have been assessed as being competent to carry out their work.

What the care home could do better:

Better processes must be put into place to make sure that any new resident being admitted to the home will not have a negative effect on existing residents` due to needs or behaviour. Before new admissions are accepted the management must ensure that adequate resources such as; staffing levels are in place so that all needs can be met. Weight monitoring must be improved to make sure that where it is identified that significant weight loss has occurred then this is reported to a senior or manager for action to be taken. Medication systems need to be improved as presently there are shortfalls that place residents at risk examples being; highlighted allergies not being picked up on admission and recorded so that all staff are aware. Medication packets are not being date labelled when first opened to allow effective audits. Three medication totals did not add up to what there should have been according to records.Some medication records were confusing, as they had not been amended when discontinued by the doctor. Handwritten medication records are not being checked by two, staff as they should be to prevent error. The home has been without a registered manager for over 18 months. The acting manager has recently left and a new manager has been appointed who must at the earliest opportunity apply to the Commission for registration. The homes` registration certificate still details the name of the previous registered manager. This must be returned to the Commission to be updated. The insurance certificate on display within the home had expired and needs to be replaced. It came to our attention that a staff member has been dismissed yet this had not been reported to the Commission as it should have been. Hot water from one outlet ( ground floor shower room hand wash basin) exceeded the recommended upper safety temperature range of 43oc. This needs to be corrected to prevent risk to residents. Attention must be paid to infection control processes. Dirty washing was stored in the only sink in the laundry and there was no liquid soap available for proper hand washing in the laundry. The back stairs were covered with bits and a build up of dust. We were told that the vacuum cleaner had broken the week before. This should have been dealt with as soon as it was known that it was broken. The shower room floor on the ground floor was stained and is in need of deep cleaning.

CARE HOME ADULTS 18-65 Holly Hall House 170 Stourbridge Road Dudley West Midlands DY1 2ER Lead Inspector Key Unannounced Inspection 29 August 2007 07:25 Holly Hall House DS0000025034.V342867.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 Hall House DS0000025034.V342867.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 Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Hall House Address 170 Stourbridge Road Dudley West Midlands DY1 2ER 01384 252219 F/P01384 252219 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) Select Health Care Limited Teresa Owen Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 2006 Brief Description of the Service: Holly Hall House is registered to provide care to 10 service users who have a diagnosed learning disability and fall within the younger adults age range (1865 years). A condition has been approved for the home to provide care to 1 named service user who has a learning disability who is over 65 years of age. Holly Hall House is situated on the main Stourbridge Road in Dudley, it can be easily accessed by public transport. The local public transport enables service users to visit other neighbouring areas and places of interest such as Merry Hill shopping centre and Dudley town. Holly Hall House is a large Victorian traditional domestic type dwelling. It comprises of ten single bedrooms (one with en-suite facilities), two bathrooms, one shower room, five toilets (including the ones available in the shower/ bathrooms) an office, kitchen, laundry, dining room and lounge. Car parking is available at the front of the property and garden areas to the side and rear of the home. The home provides service users with opportunities to develop skills for independence. All service users are encouraged to use suitable community facilities and resources and attend day care facilities or college. The charges for this home range from £367-£1050 per week. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day, by one inspector between 07.25 and 15.00 hours. Prior to the inspection a questionnaire was sent by us for managers to complete, to give us up to date information about the home. We spent most of the inspection time in the dining room. This is the main room used by residents’ during the day. Here we could observe resident and staff involvement and breakfast time. During the inspection two staff and four residents’ were spoken to. All other residents were observed or spoken to in less detail. We looked at records regarding two residents, one of whom was the newest person to be admitted to the home. Records looked at focussed on admission processes, care planning and daily care. We looked at three staff files to see how well the home is doing regarding recruitment, training and supervision. We randomly looked at the premises, which included the dining room, living room, bathrooms, toilets and two bedrooms. We looked at medication systems to assess the safety, service and health and safety records. What the service does well: The atmosphere of the home is warm and welcoming. It has a strong ‘ homely’ feel. The staff, are friendly and polite and respond well to the residents’ in their care. As with other inspections we observed residents’ being confident to approach staff with requests, questions or just for a talk. Residents in general get on well. There was continual, friendly conversation between them throughout the day. Residents were all dressed appropriately. They purchase and choose their own clothes and hairstyles. Opportunities are open to all residents to access educational input and other resources within the community. All residents have very active leisure times. Trips, outings and holidays are offered on a very regular basis. The home has it’s own transport which allows regular outings and access to the wider community. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 6 The premises are well maintained. Furniture, fixtures and fittings are all domestic in style. Resident bedrooms are all personalised with their own belongings. Residents’ are encouraged to maintain contact with family and friends. Residents’ spoken to confirmed that they like the home and living there. What has improved since the last inspection? What they could do better: Better processes must be put into place to make sure that any new resident being admitted to the home will not have a negative effect on existing residents’ due to needs or behaviour. Before new admissions are accepted the management must ensure that adequate resources such as; staffing levels are in place so that all needs can be met. Weight monitoring must be improved to make sure that where it is identified that significant weight loss has occurred then this is reported to a senior or manager for action to be taken. Medication systems need to be improved as presently there are shortfalls that place residents at risk examples being; highlighted allergies not being picked up on admission and recorded so that all staff are aware. Medication packets are not being date labelled when first opened to allow effective audits. Three medication totals did not add up to what there should have been according to records. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 7 Some medication records were confusing, as they had not been amended when discontinued by the doctor. Handwritten medication records are not being checked by two, staff as they should be to prevent error. The home has been without a registered manager for over 18 months. The acting manager has recently left and a new manager has been appointed who must at the earliest opportunity apply to the Commission for registration. The homes’ registration certificate still details the name of the previous registered manager. This must be returned to the Commission to be updated. The insurance certificate on display within the home had expired and needs to be replaced. It came to our attention that a staff member has been dismissed yet this had not been reported to the Commission as it should have been. Hot water from one outlet ( ground floor shower room hand wash basin) exceeded the recommended upper safety temperature range of 43oc. This needs to be corrected to prevent risk to residents. Attention must be paid to infection control processes. Dirty washing was stored in the only sink in the laundry and there was no liquid soap available for proper hand washing in the laundry. The back stairs were covered with bits and a build up of dust. We were told that the vacuum cleaner had broken the week before. This should have been dealt with as soon as it was known that it was broken. The shower room floor on the ground floor was stained and is in need of deep cleaning. 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. The summary of this inspection report can be made available in other formats on request. Holly Hall House DS0000025034.V342867.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 Hall House DS0000025034.V342867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3. Quality in this outcome area is adequate. The new resident had their needs assessed before they were offered a place at the home. More attention to this process must be paid to ensure that any new resident will not cause any disruption to the lives of residents already accommodated and that adequate staffing is in place to ensure that their full needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is not often that new residents are admitted to the home, as vacancies do not occur. One new resident has been admitted since the last inspection. We looked at records regarding this new resident and observed him during the day when he was in the home. We saw written evidence to confirm that an assessment of need had been undertaken and that the resident had visited the home three times before admission. One of these times being for a tea visit to meet the other residents. This new resident is more dependant than the other residents’ and has needs that require one to one staffing. If he does not have this one to one attention he self harms by head banging. We observed three times when he banged his Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 10 head on the table in the dining room. One time was during the morning and two in the afternoon. We noticed that this behaviour did have an impact on the other residents’ who stopped what they were doing, or stopped conversation and turned to see what was going on. At times we noted that residents were quite startled by the noise and this behaviour. Staffing levels at the home are not adequate to meet this persons needs. On the morning of the inspection there were four staff, this included the manager. The manager sat with this service user most of the time, a senior at one time was doing the medications, a carer helping with the breakfast, which left one staff member for the other residents. On afternoon shifts often there are only three staff. With one to give the resident one to one attention, the evening meal to prepare and the needs of other residents to meet, staffing levels are not sufficient. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. Care plans do need some ‘ fine tuning’ to ensure that all needs are captured. Residents are very much encouraged and enabled to make decisions about their lives and are supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at two care plans. One was seen to be comprehensive and captured most care needs, goals and aspirations. We did note however, that the care plan relating to one resident’s ( K) behaviour was not adequate and on one occasion had not been followed. The care plan read;’ To talk to K about any problems she may have which could become a factor for any displays of behaviour’. Yet from reading daily notes 8.6.07 when she had displayed behaviour she had been asked to ‘ go to her room to calm down’. There was no evidence to confirm that this way to deal with behaviour was documented or that it had been agreed with other professionals involved. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 12 We looked at records for the new resident and saw that the previous care provider had produced a care plan for the prevention of choking. We did not see that a care plan had been produced by this provide,r to prevent the incidence of choking, which could place the resident at risk. We did note that there was little evidence to confirm that residents are being reviewed by their funding authorities on an annual basis as they should as an additional measure to ensure needs continue to be met and that the residents are being safeguarded. The manager covering the home at the time of the inspection told me; “ Most of the time, once a service user is made permanent residents do not then have an allocated social worker. I will follow this up though”. It is clear from spending time at the home, listening to what was going on, speaking to residents’ and viewing records that residents where possible are encouraged to make decisions about their lives. All but the new resident are fairly independent and make choices on what they want to do on any given day, what they eat and if they want to spend time alone. One resident told me; “ Today I am going out”. Residents are very much encouraged to take risks as part of their independent living. One resident told me; “ Sometimes I go out on the bus with.. ( another resident) to Brierley Hill or Merry Hill to go shopping. Other residents also go out independently and use public transport. One resident proudly showed me her bus pass. Holly Hall House DS0000025034.V342867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Quality in this outcome area is Excellent. All residents who want to, engage in resources within the community to enhance their personal development. The home offers each resident access to the community, trips and outings virtually on a daily basis. Each resident has the opportunity to go on holiday at least once every year. Residents are very much encouraged to maintain contact with family and friends. Residents are given the opportunity to choose and plan meals, they are encouraged to eat a healthy diet This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of residents attend some form of educational or structured facility in the community. One resident told me; “ I go to college three times a week. I like it. I have many friends there”. Another told me he was going to the Age Concern centre, which he enjoys. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 14 One issue was raised with the manager about the new resident. His activity record stated that he was to go swimming weekly. However, records we looked at only confirmed that he had been swimming once since being admitted to the home. The residents are offered opportunities every day to go out and access community facilities either independently or as a group. On the day of the inspection a couple went to Dudley and a couple went to Walsall. Activity records for the two residents who were case tracked showed regular activity and access to the community as follows; 1.7.07 been out to get birthday cards. 2.7.07 went out for a meal. 4.7.07 disco. 7.7.07 Bewdley then Bridge North. Carvery at the Dudley Arms. 11.7.07 Ride out. 21.7.07 Out to dogs. 23.7.07 swimming and 1.7.07 Walked to the hospital to see other resident. 2.7.07 Pub meal. 3.7.07 Out to Woodside. 4.7.07 Out in the mini bus, went shopping and had nails done. 7.7.07 Car boot. 9.7.07 Brierley Hill. 23.7.07 Woodside. We saw photos on the walls of recent trips and outings examples of which follow; Rhyl, Twycross Zoo. All residents were very excited about their forthcoming caravan holiday the second week of September. Most residents have contact with family and friends. Records confirmed this; 12.7.07 visit from S .6.8.07 Been out with S. 26.8.07 went to S house and 8.1.07 Aunty came to speak to K. 12.2.07 Gone to see Aunty. 19.2.07 Aunty called. Residents told me that they are involved in menu planning. They are also involved in food shopping at local supermarkets and are involved in meal preparation. We saw a number of residents during breakfast time getting their own cereal and toast. One resident has a cup with a lid and hook attached. This allows her to make her own drink then carry it safely. She hooks it onto her zimmer frame when mobilising. We were provided with new menus to look at. These have been produced in a pictorial format to aid understanding and presented to a very good standard. I looked at food stocks in the kitchen these were satisfactory and varied. We saw that there was plenty of fresh fruit available. One resident told me; “ The food is very good, especially when she cooks it,” pointing to a female staff member. The staff member told me; We are experimenting at the present time. I have introduced foods that are a bit more spicy and am encouraging more salads”. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is adequate. Residents personal care needs are supported to individual preferences. Some improvement is needed in terms of health care monitoring. A number of shortfalls were identified concerning medication, which need attention, as they potentially place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was plenty of evidence to confirm that residents’ personal care is managed the way they want it to be. The majority of residents are able to attend to their own personal care needs and they are allowed to which, promotes privacy and dignity. One resident K had a bath and washed her hair independently during the inspection. We saw that her nails were nicely polished and manicured. She told us; “ I go to the nail bar every week in Brierley Hill. They polish and do my nails for me”. Generally, all residents purchase or are involved in purchasing their own clothes. Two residents came back from shopping during the inspection with new clothes. All choose their own hairstyles. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 16 Overall there was evidence to confirm that the two residents’ case tracked have access to a range of health care services as follows; 1.3.07 Dr stopped some medications. 21.3.07 smear teat and Depo injection. 20.4.07 Seen Dr about eye. 9.7.07 Dentist. 26.7.07 Saw Doctor. Weight Jan 07 14 St 8 ¾ llbs. July 07 14 St 2 llbs. We were concerned however, to discover that one resident had lost over a stone in four months. In March 2007 weight was 9st 8 llbs. In July 2007 weight 8st 3 llbs. Although the previous care provider had a care plan in place which stated ‘ weigh monthly. Any concerns record and inform nurse’. This resident has a thyroid dysfunction. This weight loss should have been reported to prevent risk. Similarly, a risk assessment to prevent constipation had been carried out but the overall score had not been recorded. The total score should have been 9. The risk assessment advised with this score rating to encourage mobility, increase fluid intake to 2 litres in 24 hours and introduce half cup of prune juice a day. I asked the manager on duty to show me the prune juice. She was not able to as there was not any on the premises. We did see some good, safe practice concerning medications examples being; The home has an approved medication trolley which is chained to the wall when not in use. There were protocols in place for medications prescribed on an’ as required ‘ basis such as Lorazepam. There were no staff initial gaps on medication records for regular medication administration. Where there was a choice of dosage for Co-Codamol and Senna staff recorded how many had been given, one or two. We did highlight a number of shortfalls which need to be addressed as they potentially place residents at risk as follows; A requirement was made following the last inspection for risk assessments to be in place for one resident who self administers his inhaler, to date this has not been met. A requirement was also made previously, for the home to review the medication policy, this has not been met. We were very concerned to discover that one resident was allergic to Elastoplast, new medication and Trimethroprim. The previous care provider had highlighted this on paper work which was forwarded to the home. The home had failed to see this information. We looked at the allergy section on the current medication record, this section had not been completed. This omission placed this resident very much at risk as the staff, were not aware of these allergies. We did four medication audits and found that three of the four totals of tablets against records were not correct. Staff are not date labelling medication packets when first used which prevents effective audits taking place. We did not see that a date of opening had been applied to a tube of cream Hydrocortisone, as it should have been. We noted that a number of medications for JE and JE were on the medication record but not being initialled when administered. We told that the doctor had Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 17 discontinued these medications. The medication records had not been amended as they should have been. Holly Hall House DS0000025034.V342867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. Processes are in place for residents to complain if they have the need. The management however, must ensure that the complaints procedure is current and valid to prevent confusion. The home has processes in place to increase the protection of vulnerable people. It has a good past history of reporting incidents and allegations to the Commission, but has failed to report the most recent when a member of staff was dismissed which, could place residents at risk from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has in place procedures for residents to access if they are not happy. A copy of this procedure is available in each room. To increase understanding the procedure has been produced in writing and pictures. No complaints have been made about the home. We asked one resident what they would do if they were unhappy and was told; “ I would speak to the staff”. A requirement was made following the last inspection for the home to amend the complaints procedure as it referred to the regulator as the NCSC instead of CSCI. The organisation has not been called NCSC since April 2004. This requirement has not been met. If someone were to try and contact us this may cause confusion. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 19 The home has in place policies and procedures to protect residents from harm and abuse. The majority of staff files we checked held certificates to confirm that they have received abuse awareness training which, is positive. Two incidents have occurred since the last inspection. One involving two residents’ and one allegation that was made about a night staff member sleeping in a resident’s bed. These have been reported to Social Services and to the Commission. We were told about a staff member being dismissed recently. This incident was not reported to the Commission. Who ask that a full report of the incident be made in retrospect. As we are not aware of the detail that led to the dismissal it could be that residents were at risk and we were not aware. We checked two residents money held in safe keeping against balances and receipts and were pleased to find that these were correct. Holly Hall House DS0000025034.V342867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,30. Quality in this outcome area is good. The home is well maintained, comfortable and safe. Infection control processes however, are not adequate and need to be improved upon to prevent infection risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is in a good location to meet the needs of the service users’. Bus routes run past the home to Dudley one way and Brierley Hill through to Stourbridge the other way. The home is near to the Merryhill shopping centre. There are a number of small shops local to the home. The home is well maintained. Redecorating and refurbishment work is carried out on a rolling programme or when the need arises. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 21 The home offers a nice sized dining room and separate lounge. These are well decorated, comfortable and homely. There is sufficient space indoors to cater for the ten residents who live at the home. Externally the home has gardens and a good size car park. A small covered area is available outside for residents to use when they have a cigarette. We looked at two residents bedrooms. One resident showed us his own bedroom. This was nicely decorated and well maintained. The room held numerous personal belongings making it feel personalised and homely. This resident told me; “ I like my room”. When asked, he confirmed; “ No there is nothing that I want for my room that I have not got”. We saw that the radiator in the room was guarded and the wardrobe secure to ensure safety. The other bedroom that we viewed was also very comfortable, well maintained and safe. I asked another resident if she liked her bedroom. She told me; “ Yes I do, very much”. We were disappointed with infection control processes within the home. It has been highlighted in previous reports about the need to ensure that risk minimisation processes are in place in the laundry due to there only being one sink. We saw dirty clothes stored in the sink. There was no liquid soap available in the laundry for hand washing purposes. We saw that the flooring in the ground floor shower room was stained and badly in need of a good, deep, clean. We saw that the stair carpet was covered in bits and a build up of dust. We raised this issue with the manager covering the home. She told me that the vacuum cleaner had broken the week before. We did not detect any unpleasant odour in the home. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35. Quality in this outcome area is adequate. Fifty percent of the care staff team have attained NVQ level 2 or above in care which, means they have been assessed as being competent to undertake their work. Recruitment processes and staffing levels must be improved to prevent risks to residents’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Seven of the fourteen care staff employed have attained NVQ. This means that half of the care staff team have been assessed as being competent to carry out their work. The home’s annual quality assurance assessment told us that other staff are working towards this award. Two new staff both confirmed that they too, are in the process of enrolling for their NVQ. Concerns have been raised in previous inspection reports about the home employing staff before their full Criminal Records Bureau ( CRB) check has Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 23 been received. We were concerned to identify that she had commenced employment on 3.7.07 however, her CRB was dated 6.8.07. As this person is being appointed as manager the risk is higher as essentially there is no-one on site to supervise her. We were pleased that staff files are held securely to increase confidentiality. As stated in the first section of this report staffing levels do not always allow the required 1:1 support for the one resident who needs this as well as adequate staff to support the remaining residents’ and fully meet their needs. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. Three different managers have been in post in eighteen months which, has had a negative impact on the home. Quality assurance processes need some ‘fine tuning’ to ensure that the home is run in the best interests of the residents’. Issues surrounding health and safety need to be improved to prevent risk to residents’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three different managers have been employed at the home over an eighteen month period. There has not been a registered manager at this home for Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 25 eighteen months. On 31 July 2007 we received written confirmation from the regional manger that the third manager has been appointed. Hopefully, this manager will regain direction in the home to ensure it’s smooth and safe functioning and prevent future shortfalls occurring. The home uses a number of methods to gain the views of residents and other stakeholders such as questionnaires. To date there is no evidence to confirm that the outcome of analysis of these questionnaires have been published as should happen. Resident meetings are held fairly regularly, usually every four to six weeks. These meetings give service users’ the opportunity to make suggestions and make their views known. The regional manager visits the home very regularly, which is positive. A report of her findings is produced every month. During her visits she undertakes audits in certain areas examples being; resident money and medications. We did not see a process by which all National Minimum Standards are assessed which, should be happening. The home provided us with a completed annual quality assessment document whereby they were able to tell us what they do well, what has improved and what further improvements are needed. We were told that West Midlands Fire Service had carried out an inspection within the last month and were pleased with their findings. We looked at the kitchen. This is a good sized room. We found that it was clean. We saw documents to prove that fridge and freezer temperatures are taken and recorded. We saw a number of dried foods such as porridge and spices in open packets that had not been placed in air tight containers as they should. We noted that the windows do not have fly screens installed and asked the covering manager to ask Environmental Health if these are needed. The manager told me later that fly screens are to be fitted in the next week or so. We looked at a range of certificates and records to prove that appliances and equipment is being serviced as it should be such as the fire alarm system and fire fighting equipment. We found that the temperature of the hot water in the ground floor shower room hand wash basin was 48.7oc which exceeds the recommended upper safety level of 43oc. We informed the covering manager of this. We looked at staff training records. Generally, these were in good order and proved that staff have either received training or it is being arranged. Fire training was provided by staff by an external person during the inspection. A number of residents joined in this training. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 26 We were concerned however, to discover that one waking night staff lacks important training such as abuse awareness, moving and handling , challenging behaviour and first aid. This training deficit presents risk to residents’ as she works alone at night, with only a sleep in staff member. Holly Hall House DS0000025034.V342867.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 2 3 2 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 4 25 x 26 3 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 2 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 4 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 2 x x 2 x Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? aSTATUTORY 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 YA19 Regulation 13(4)( c) Requirement Staff must be vigilant when undertaking weight monitoring. Any significant, unexplained weight loss should be reported to a senior or manager to take action on. Concerns regarding this were highlighted to the manager in attendance during the inspection. This requirement has been made to prevent risks to residents and to keep them safe. The registered person and manager must ensure that a risk assessment is carried out for the service user who self medicates their nebuliser. Timescale of 08/11/06 not met. Timescale for action 29/08/07 2 YA20 13(2) 30/09/07 Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 29 3 YA20 13(2) Efforts must be made to identify any known allergies that residents may have and ensure that these are highlighted on medication an d other records. Concerns regarding this were highlighted to the manager in attendance during the inspection. This requirement has been made to prevent risks to residents and to keep them safe. 29/08/07 4 YA20 13(2) Medication boxes must all be 29/09/07 date labelled when first used to enable effective audits. This requirement has been made to prevent risks to residents and to keep them safe. 5 YA20 13(2) Medication records must be kept up to date. Where medication has been discontinued by the doctor these must be removed from the medication records and records kept to state when they were discontinued. Concerns regarding this were highlighted to the manager in attendance during the inspection. This requirement has been made to prevent risks to residents and to keep them safe. 29/08/07 Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 30 6 YA20 13(2) More care must be taken to 29/08/07 ensure that medication is administered correctly and that medication records against current balances of tablets remaining can confirm this. Concerns regarding this were highlighted to the manager in attendance during the inspection. This requirement has been made to prevent risks to residents and to keep them safe. 7 YA20 13(2) Medication records must be accurate and up to date regarding how many tablets should be given at any time. Concerns regarding this were highlighted to the manager in attendance during the inspection. This requirement has been made to prevent risks to residents and to keep them safe. Staffing levels must be adequate at all times to maintain safety and meet resident needs. Concerns regarding this were highlighted to the manager in attendance during the inspection. This requirement has been made to prevent risks to residents and to keep them safe. 29/08/07 8 YA33 18(1)(a) 15/09/07 Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 31 9 YA42 13(4)( c) Hot water temperatures must remain within the recommended safety levels of 38oc- 43oc. Concerns regarding this were highlighted to the manager in attendance during the inspection. This requirement has been made to prevent risks to residents and to keep them safe. Priority must be given to ensure that night staff receive the following training; First aid, moving and handling, abuse awareness, challenging behaviour. This requirement has been made to ensure that residents as far as possible are free from risk and harm. 15/09/07 10 YA42 13(4)( c) 01/11/07 Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 32 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 YA20 Good Practice Recommendations The registered person and manager must ensure that the homes medication policy/ procedures are fully revised. Timescale of 20/01/06 not met. This to include; Ordering and receipt of medications. Medication errors. 7 day retention of medication after death. The policy must be as one document, indexed and easy for staff to retrieve information. 2 YA20 It is strongly recommended for safety that two staff confirm and sign medication records that are hand written to ensure that the information is correct. Seniors and managers should not be appointed on a POVA first as it would not be possible to effectively supervise them. Management processes should ensure that reporting to the Commission is robust in terms of staff dismissals. A report should be forwarded to the Commission concerning male staff member ( S ) dismissal. The registered person and manager must ensure that the complaints procedure is amended to include : The CSCI.( Not NCSC)where the telephone number is detailed. 3 4 YA34 YA37 5 YA22 Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 33 6 YA30 Equipment such as the vacuum cleaner should be in good working order at all times to ensure the premises are clean. The ground floor shower room floor should be deep cleaned. Action must be taken to ensure that the black debris does not build up in the corner of the ground floor bathroom. Dirty clothes should not be left in the laundry sink. Liquid soap should be available at all times in the laundry. 7 YA39 The registered person and manager should ensure that recent outcomes of resident satisfaction surveys are published. 8 YA42 Fly screens be installed on the kitchen windows. All open packets should be stored in air tight containers once opened. Holly Hall House DS0000025034.V342867.R01.S.doc Version 5.2 Page 34 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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