Inspection on 17/11/05 for Holly House

This inspection was carried out on 17th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holly House 09/05/08

Holly House 29/10/07

Holly House 27/04/07

Holly House 24/03/05

Holly House 12/07/04

Holly House 09/02/04

Similar services:

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Snydale Care Home

Larchfield Manor

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Beeches The - North Yorkshire County Council

The Grove Waltham

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Holly House 124 High Street Burringham Scunthorpe North Lincolnshire DN17 3LY Lead Inspector Mrs Kate Emmerson Unannounced Inspection 17th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly House Address 124 High Street Burringham Scunthorpe North Lincolnshire DN17 3LY 01724 782351 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) PB Residential Care Limited Mrs Jayne Hatfield Care Home 48 Category(ies) of Dementia - over 65 years of age (47), Old age, registration, with number not falling within any other category (48) of places Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The bedroom in the cottage with the ensuite bathroom must only be used for service users in the category of OP. Nominated staff to be allocated for each area - Trent House, Holly House and the Cottage and this to be indicated on staff rotas with staffing levels assessed under Residential Forum guidelines 30th June 2005 Date of last inspection Brief Description of the Service: Holly House is situated in the centre of the village of Burringham close to Scunthorpe and local transport links. The home had consisted of three separate buildings known as Holly House, The Cottage and Trent House. The addition of a conservatory linked the Cottage and Holly House. An extension linked Holly House to Trent House forming a dining room, meeting room, reception area, kitchen and office. The older parts of the property had accommodation over two floors. A mechanical stair climber has been provided in The Cottage and Holly House to assist service users with the stairs. The accommodation at Trent House was purpose built and on one level. The home is registered to accommodate 48 male and female service users in the category of old age and including up to 47 service users with dementia. It is a condition of registration that service users with dementia must not be accommodated in the bedroom in Cottage with a bath in the ensuite. Attractive secure garden areas were provided for service users. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in November 2005. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spent time in the home watching how the care was given. The inspector spoke to 7 people who lived in the home and were able to answer some questions about the home. The inspector also spent time with other people who were not able to say much about the care they got or how the home was run but were able to say if they were happy at the home. The inspector also spoke to staff who were on duty at the time of the inspection. Paper work kept in the home was also seen, this was to make sure checks to ensure staff were safe to work in the home were done before they started and that they had been trained to their job safely. Paperwork was looked at to make sure that the home and the things used in it were safe and were checked regularly. The home had had two complaints prior to the inspection one of which had resulted in a Protection of Vulnerable Adults investigation. The management had been very helpful in the investigation and had made sure that everything was done to keep the service users safe and the routines in the home had been changed to ensure this. What the service does well: The home was clean and tidy and well decorated. There was lots of space and different places to sit. Training for the staff was given on a regular basis and care staff had had a wide variety of training to help them do their job safely. The residents said that the staff were good and were kind and polite to them The care people needed was written down and checked often by the staff to make sure that there had been no changes. Residents were encouraged to do things for themselves where they were able. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 6 The home had enough staff in the home at any one time to make sure everyone could be cared for. The person who owned the home had spent a lot of time improving the home and he visited the home frequently. The residents could enjoy the gardens safely. Garden furniture and raised flowerbeds had been provided for the residents to use. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 All service users had had their needs assessed before moving into the home. EVIDENCE: There was evidence that all the service users had had detailed assessments of their care needs completed prior to being offered a place at the home. Files of two service users admitted just prior to the inspection were examined. One, admitted a week before, had a detailed assessment and care plan completed. The other, who had been admitted only the previous evening as an emergency, had had a basic assessment and care plan completed on admission and risks had been identified and action plans put in place. The home must be commended for the assessment processes in place. The home advised service users or their relatives verbally that the home, following assessment could meet their needs but did not confirm this in writing to them; this is required under the Care Home Regulations. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, and 10 The service users health, personal and social care needs were met and were recorded in well developed and consistently maintained care plans. Service users were enabled to self medicate if they wished. Service users felt they were treated with respect and that their privacy was upheld. EVIDENCE: A random selection of care plans was examined. The care plans had been consistently maintained and were generally very detailed and well organised. A format had been developed and implemented indicating that the service user had agreed to the care plan. The care plans were generally evaluated monthly with detailed recording and care plans had been updated as needs had changed. There was appropriate Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 10 use of risk assessments particularly for service users at risk of wandering and falls. There were still some minor deficiencies that need to be addressed. • Some of the care plans had not been dated or signed by the staff when developed. • Care packages had been formally reviewed annually. It is recommended that this be done 6 monthly. There had been improvement in the risk assessment and care plans for those at risk of developing pressure sores. The manager had taken advice from the District Nurse and had developed training for the staff in pressure area care. Following a recent complaint the care plans now contained detailed care plans regarding the service users sleep patterns. At the last inspection there were issues regarding the standards of recording where service users suffered frequent skin tears. Risk assessments and care plans had been completed but daily records did not adequately detail the circumstances of how/ when these had occurred or were discovered. There was evidence from staff meetings minutes that this issue had been addressed and evidence of liaison with the District Nurse. Body maps showing where and when skin tears were occurring had been implemented. However accident records and diary sheets detailing the circumstances where skin tears had been found were still not being completed. Details regarding the service users dietary needs were recorded on assessment, nutritional screening and care plans were being completed. Service users were being weighed monthly. Appropriate scales had been purchased for service users who were unable to weight bear. There was evidence that staff involved the Continence Advisor in care planning where needs were identified in this area and training had been provided for staff. Records of contact with GPs and other medical professionals were maintained. A policy and procedure for the safe handling of medication was available in the home. Service users were enabled to self medicate if they wished and one service user was self-medicating. Care plans for self-administration had been developed and risk assessments had been completed and these now included assessment of the capability of the service user to self medicate. At the last inspection there were some issues regarding controlling the temperature in the storage facilities for medication due to the very warm weather. The manager stated that they had continued to monitor the temperature and had tried different options to control the temperature in this Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 11 area in the summer. The manager stated that air conditioning units were to be purchased. The manager and staff responsible for medication in the home had completed an accredited distance-learning course in the safe handling of medication. Service users stated that the staff respected their privacy and dignity when they were assisting them. They stated that staff always knocked on doors before entering their private space and used their preferred term of address. They stated staff were polite and kind when addressing them. Observation of staff interaction with the service users confirmed this. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 The service users were enabled to maintain contact with relatives and friends as they wished. EVIDENCE: Information regarding arrangements for maintaining contact with relatives and friends was included in the service users guided and statement of purpose. Service users had access to private space to receive visitors either in their own rooms or the training room. The service users were able to choose whom they wished to see and there was now only one point of access to the home this could be more easily managed. Family and friends were invited to social events in the home. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Procedures were in place to ensure that complaints were taken seriously and acted upon. There were systems in place to ensure that service users were protected from abuse although the manager must continue to monitor routines in the home to ensure that these are arranged to meet service users preferences. EVIDENCE: The home had a detailed complaints procedure, which was displayed in the home and was also contained in information provided to service users. The home had received no complaints since the last inspection but the commission had received two complaints. The Commission received a complaint in July 2005 from the relative of a service user regarding the care provided and record keeping in relation to a fall and subsequent hospital admission. The complaint was a made 9 months after the incident and the staff member involved had left the home 2 months after the incident. The complaint was investigated and the outcomes were as follows, regarding the circumstances of a fall - unresolved, poor recording of accidents - founded, procedures regarding admission to hospital - unfounded and providing medication and overnight clothing for admission to hospital unresolved. The Commission an anonymous compliant regarding the lack of choice service users had in the times to get up and go to bed and that service users were Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 14 made to get up too early by the night staff, this resulted in a protection of Vulnerable Adults investigation. This complaint was founded. The management was cooperative during the investigations and have been proactive in meeting requirements arising from the complaints. Service users confirmed that they had choices in getting up and going to bed and care plans had contained detailed information about service users individual sleep patterns. The policies and procedures for the protection of vulnerable adults were adequate in terms of linking to the Local Authorities procedures and providing information on referral to the Local Authority Protection of Vulnerable Adults team. A flow chart for referral had been developed and displayed in the home. Leaflets had been obtained from the Local Authority regarding abuse and were displayed in the home. All the staff had received training in the protection of vulnerable adults this year and this was being repeated, targeting night staff, following the recent investigation. Training in managing challenging behaviour and dementia awareness had been provided this year to ten staff. Staff recruitment now offered adequate protection for service users. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home was exceptionally clean and tidy. The refurbishment plan was complete and the home provided spacious, comfortable and well-decorated accommodation. EVIDENCE: Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 16 The home has undergone extensive refurbishment and improvement over the past three years and offered spacious well maintained and homely accommodation. The home was exceptionally clean and tidy throughout. The manager had audited all the rooms and indicated where any non-provision of furniture or fittings as listed in standard 24 was the service users choice. The manager was advised that the service users should sign to evidence this. The issues with the hot water in the new bathroom had been addressed. The manager provided evidence that they had systems in place to minimise the risks of Legionella. The staff were still cleaning commode pots in the bathrooms and due to the risk of cross infection the proprietor should consider providing alternative facilities. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels were appropriate to meet the service users needs. The service users were very positive about the staff and their attitudes towards them. Staff rotas did not detail all the staff working in the home at any one time. Staff recruitment had improved and now offered adequate protection for service users. Staff training was available to meet mandatory and service user specific requirements but management monitoring of training needs must be further developed to ensure that mandatory training is kept up to date. EVIDENCE: Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 18 The home was assessed under the residential forum guidelines and the manager had good systems in place to monitor the dependency of the service users and provide appropriate staffing as per these guidelines. There was evidence that the staffing levels were appropriate to the dependency of the service users. A staff rota for the ancillary staff was not available and must be maintained. The staff stated that there had been an impact on the routines of working in the home since the recent complaint and that they were much busier now on the morning shift but stated that service users needs were being met at that time. The proprietor and manager were advised to continue to monitor this to ensure that service users needs continue to be met at this time. The service users said that the staff were ‘wonderful’, ‘very good’, ‘very nice’ and stated that ‘they will do anything for you’. The management and staff were committed to NVQ training. Six staff of the twenty-six staff had achieved NVQ 2 and one staff member had achieved NVQ level 3, and seven were training towards NVQ level 2. Examination of staff files for the two staff that had commenced employment since the last inspection showed that there were improved practises in place and the manager had ensured that staff had 2 written references and Criminal Records Bureau (CRB) check before employment. Mandatory training had continued to be provided at regular intervals and evidence was provided to show that requirements from the previous inspection were being met. All staff had received moving and handling and fire training since the last inspection. Food hygiene training had been provided for all the kitchen staff and 3 carers. Training for first aid training was booked for 13th December 2005. The manager must ensure that she develops a system of monitoring mandatory training to ensure that this is kept up to date in future. Training to meet the specific needs of the service users had been provided in challenging behaviour, dementia and pressure area care. The manager, deputy manager and cook had also completed a course on nutritional health. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 and 38 Staff received regular formal supervision. The manager ensured the health and safety of the service users and the staff through policies and procedures and training. EVIDENCE: There was evidence that staff received regular formal supervision at six weekly intervals. Records were maintained of the content of the supervision. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 20 There had been continued improvements in the management of health and safety of staff and service users since the last inspection. There were policies and procedures to support practise and staff training through induction, in-house and external courses had been provided. Mandatory training had been provided in moving and handling and fire safety since the last inspection. Training in first aid had been booked for December 2005. Records showed that weekly fire alarm and monthly emergency lighting tests had been completed. Fire drills were held regularly and records showed that all staff had attended a fire drill this year. Requirements from the previous inspection had been met. Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 X 3 Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 22 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 OP3 Regulation 14(1)(d) Requirement The registered person must confirm in writing that the home is suitable for the purposes of meeting the service users needs. The registered person must ensure that records in diary sheets and accident books are maintained regarding the circumstances where a skin tear has occurred . (Previous timescale - with immediate effect- not met) The registered person must ensure that all staff are included on the staff rota. The management must monitor the impact of the recent changes in working routines to ensure that service user needs continue to be met. The registered person must ensure that management systems are developed to ensure that mandatory training is kept up to date Timescale for action 01/01/06 2 OP8 13(4) 17/09/05 3 OP27 17(2) 17/09/05 4 OP30 18(1) 30/01/06 Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 23 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 OP7 Good Practice Recommendations The registered person should ensure that care packages are formally reviewed 6 monthly with all interested parties. Care plans should be signed and dated by staff when developed. The registered person should ensure that the service users have sgned to evidence their choice not to have all the standard furniture and fitttings in their room. The registered person should provide alternative facilities to clean commode pots other than bathrooms 2 3 OP24 OP26 Holly House DS0000002887.V268302.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 House DS0000002887.V268302.R01.S.doc Version 5.0 Page 25 - 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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