Inspection on 02/11/05 for Holly Park

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Park 12/11/08

Holly Park 13/11/07

Holly Park 09/01/07

Holly Park 16/05/06

Holly Park 28/06/05

Holly Park 22/02/05

Holly Park 06/01/05

Holly Park 16/12/04

Holly Park 30/09/04

Holly Park 29/06/04

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

CARE HOMES FOR OLDER PEOPLE Holly Park Clayton Lane Clayton Bradford BD14 6BB Lead Inspector Susan Knox Unannounced Inspection 2nd November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holly Park DS0000029171.V258801.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 Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly Park Address Clayton Lane Clayton Bradford BD14 6BB 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) 01274 883480 01274 816120 hollypnh@aol.com Park Homes UK Ltd Care Home 43 Category(ies) of Dementia - over 65 years of age (43), Physical registration, with number disability over 65 years of age (43) of places Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28 June 2005 Brief Description of the Service: Holly Park was converted from a former school property. It is located in the centre of Clayton village and conveniently placed for shops, library, church and local bus route. Accommodation is provided on the ground and first floor predominantly in single bedrooms. The rooms on the first floor and in the reception area have en suite facilities. There is no passenger lift although a stair lift provides access to the first floor. There are three separate communal rooms two lounges and a dining room. Forty-three service users can be accommodated and the home is registered for nursing. (Discussions are on going about the registration) Some of these have varying degrees of mental health needs as well as physical care needs. A mix of registered nurses and care staff provides the care in this home. Holly Park DS0000029171.V258801.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 carried out by one inspector starting at 9.00 am and finished at 3.30 pm. The person in charge was Mrs J McDonald acting manager. Most of the day was spent talking to service users, staff and management. A number of documents were inspected. These included care documentation, staff training and recruitment records and fire safety checks. A full building inspection was not carried out. Discussion is ongoing with the CSCI about how to resolve the current registration and the high number that can be admitted under the DE (E) category. The providers are planning to deal with the outstanding issues within the building particularly the location of the laundry and lack of passenger lift in proposed building works. Once planning permission is granted plans must be submitted to the CSCI for approval. Progress is being made within the home and new care documentation is in place. Some staff have received dementia training and more is planned. Information about the inspection findings was given to Mrs McDonald and Mr J Sykes Operations Director. A list of requirements identified from this inspection can be found at the end of this report. What the service does well: Service users made positive comments about the staff and said the care was good and that staff were caring. Staff said the care given was good. The home has a manager who is supportive to the staff team and committed to the service users. The atmosphere in the home is relaxed and friendly. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 6 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 Park DS0000029171.V258801.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 Park DS0000029171.V258801.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): 1, 2, 3, 4. Good information both written and verbal is provided to service user and/or relative about the home. This ensures that an informed decision can be made. EVIDENCE: A folder containing copies of the statement of purpose is placed in the reception area. Also available was a copy of the last inspection report February 2005. Both providing the latest information about the home for interested parties. The service user guide was available in the bedrooms seen during the inspection. In addition a letter confirming admission is sent to new service users enclosing a copy of the above documents. Local authority contracts were available in service user’s files. Detailed pre admission assessments were available in care files. Staff confirmed during discussions that they sometimes accompany the manager to visit the prospective service user and assist with the assessment. Staff said they talk about the home and give as much information as possible. Staff were pleased that they are included in the decision making about placements. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 9 Sometimes the same staff are on duty when the service user is first admitted to the home. As good practice, the rota or admission time should be arranged to ensure this happens. This would help reassure the new resident, as a familiar person would help with the settling in period. Dementia training in the form of Person Centred Care has been started so that staff know how to meet the needs of service users with dementia. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10. Care planning continues to improve and good information is provided showing how individual needs are met. This is let down when staff fail to carry out monitoring or do not complete risk assessments. The home ensures that relatives are invited to participate in care planning. Personal care had improved but staff need to be more vigilant to service users who need more privacy than others. EVIDENCE: Care documentation was reviewed for four service users. The detail in the records continue to improve. The care planning follows on from the pre admission assessment as required to ensure that all needs at that time are addressed. The care plans are then amended as needs change. In one case the plan to weigh monthly in order to monitor weight loss was not carried out but in another this was adhered to and the weight loss was referred to the GP. The information in one care plan was confirmed during conversations with the service user and the manager. From this it was apparent that the knowledge of this service user was good and care planning was in place. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 11 Risk assessments were carried out in line with current good practice. The majority was up to date although in one case some documentation such as dependence and moving and handling assessments had not been completed. There was evidence of a relative being involved in care plans. In addition, a letter to relatives confirming the placement also offers a date for the first sixweek review and a chance to discuss the plan of care. The manager confirmed that training around the use of care documentation has been given to staff. Records of visits by the GP, optician and other healthcare professionals were seen. The home had requested a visit from the tissue viability nurse to check service users that they were concerned about she called during the inspection. For one a care plan was in place and up to date including a wound care plan and subsequent acute care plans. Due to the annual leave of the tissue viability advisers the GP and district nurses had been contacted for guidance. The nurse had some concerns about equipment and monitoring. No charts were kept to record repositioning although the manager said she was confident that this was being carried out. It is the responsibility of all staff to report faulty equipment and for qualified staff to set up monitoring charts. A review policies and procedures for monitoring pressure care is required and staff trained accordingly. From observations personal care issues had improved this was evident when talking to service users in the lounge and in bedrooms. During discussions with service users one said that other people entered the bedroom without permission. The ensuite bathroom had items stored not belonging to the service user. These issues were discussed with the manager including the provision of a bedroom key. Holly Park DS0000029171.V258801.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): 12, 13, 14. The service users miss the activity co-ordinator and although staff organise events a specialist can provide more motivation. Service users are helped to make choices and decisions about their daily lives. EVIDENCE: The activities coordinator employed at the last inspection has terminated employment. This post is being advertised. Service users miss this specialist and the structure of organised activities. Although it was said that staff provide this essential part of daily living in the afternoons such as watching old films. A bonfire event had been organised for the week of the visit. Service users were aware and looking forward to it. An entertainer visits fortnightly. It was apparent during this visit that a group of service users were enjoying socialising with one another. During discussions with service users it was apparent that they felt they could follow own pursuits. One did not enjoy joining in activities but was happy to sit and observe and then return to own room. Another was observed asking others less able about their preferences for the evening meal. It was said that the cook also talks to them about their likes and dislikes. They also said that their visitors were made welcome by staff. Holly Park DS0000029171.V258801.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, 18. Comprehensive information is displayed and provided that people know whom to contact in the event of any concerns. Service users are protected from abuse by ongoing discussions and training. EVIDENCE: The complaint procedure is displayed publicly in the home. It is also included in the statement of purpose and service user guide. In addition, a photograph of the operations director and a letter is displayed in the home giving contact details in the event of any concerns. This is good practice. The manager advised that no complaints were on going. The last complaint referred direct to the CSCI was in November 2004. Staff confirmed that discussions have been held about abuse. In addition it is part of the person centred care training course. Senior managers in the organisation would not hesitate to involve other agencies in order to ensure the protection of vulnerable service users. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20. The building is not designed for those with dementia. The provision of a passenger lift would ensure that service users need not move bedrooms if they become frailer. Many of the communal areas and some bedrooms have been redecorated to good effect. The location of the laundry makes it difficult for staff to provide an effective laundry service. EVIDENCE: Previous reports have identified concerns about the building in particular the lack of suitability for those with dementia and mobility needs. The operations director advised that the providers have plans in hand to address these issues. Once planning is agreed plans must be submitted to the CSCI for approval. Due to this commitment therefore, this report will not detail the areas of Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 15 concern. Although they will continue to be a requirement detailed at the end of this report. An in depth inspection of the building was not carried out. Individual issues were referred to the manager. The concern about at the last inspection about the new ill-fitting carpeting laid in the corridor leading to the extension has been resolved. Three communal rooms are available for service user’s use. Decoration and furnishings are satisfactory in the two lounges. One door lock was missing to the WC located near the side exit. This has been referred to for a number of inspections. The manager and operation manager confirmed that a number of new beds and headboards have been purchased. A random check of bedrooms where there was a concern at the last inspection showed an improvement. Cleanliness was good in the bedrooms seen and in communal areas. There was a malodour in the dining room and middle lounge. The laundry is inappropriately placed because staff have to leave the home to access the facilities. Plans to move the washing machines into the sluice room have failed to happen because the floor is not strong enough to hold the weight. The providers are aware of the problems and are including this in the building plans. At the last inspection the subsequent report referred to two sluice disinfectors. The operations director advised that only one sluice is provided. The second one is a sluice macerator located in the extension. This is obsolete because cardboard potties are no longer in use. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 16 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, 30. Recruitment procedures continue to improve and this helps to keep service users safe. The provision of staff training continues to improve and in turn benefits the service users. Induction training for new staff must improve in order to safeguard service users. EVIDENCE: The rota for the week of the inspection was provided. No areas of concern arose about staffing levels although senior staff had been working longer hours due to changes in personnel. There has been a recent change in a number of key posts within the home with staff either terminating employment or to another home within the group. Advertising for new staff had begun and a senior staff nurse had started. The activity coordinator’s post was being advertised and this was the one most affecting the service users. Some staff confirmed their completion of NVQ level 2 training and that they were to start NVQ level 3. Recruitment files were checked for two staff one new and one longer established. These records have improved with information available about Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 17 application, interview and suitability checks. CRB numbers are now recorded and POVA first checks. In addition two references were available as required. Included in the staff files was evidence of training attended. In one case this was Person Centred Care, Abuse Awareness, Fire Awareness, Care Foundation and Moving and Handling as an Instructor. The newer member of staff in post for two months had started her induction but this had progressed very little. Induction to NTO specification must be carried out within six weeks of employment, then foundation training within six months. In this case no moving and handling training or other statutory courses had been undertaken. The manager advised that she had given instruction on the use of the hoists. She was advised to ensure this member of staff did not carry out any moving and handling manoeuvres until full training was given. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, 36, 37. The home’s manager has effective relationships with service users and the staff team and the home is well managed. Service user’s money is safeguarded. Staff supervision must be implemented to ensure that staff work effectively for the benefit of service users. Health and safety working practices must improve in order to safeguard people in the home. EVIDENCE: The acting manager has applied to the CSCI to be considered as registered manager of the home. Once the final checks are returned a fit person interview will be arranged as the last part of the regulatory process. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 19 Staff confirmed that the manager is approachable and they would contact her with any concerns. Staff are involved in decision-making. Staff meetings are held and staff confirmed this. It was clear from observations that the manager had a good positive relationship with service users. An up to date public liability insurance certificate was displayed as required. Up to date records were available of personal allowances belonging to service users held for safekeeping. No excessive amounts were held. The record for the amounts of fees paid on behalf of service users including funding by the local authorities was also available for inspection. Supervision of staff as still not started. A time scale for completing the first session for all care staff was agreed. The testing of fire tests and emergency alarms is still not being carried out weekly as required. This is due to a change in personnel. New maintenance staff are due to start soon. This is a common problem at this home and as discussed with the manager, as it was last time, it is her responsibility to ensure these essential tests are carried out. Fire drills include staff names as required. The safety check for wheelchairs and bed rails has not been carried out since the beginning of the year. This also was referred to at the last inspection when the manager was advised to deal with this urgently. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 3 1 2 2 Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 21 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 OP4 Regulation 12 Requirement The environment does not meet the needs of those with dementia therefore a plan of change is required. Staff must be more vigilant in recording monitoring forms and completing risk assessments. Ensure that appropriate door locks are fitted to WC doors. Also that bedroom keys are offered to service users assessed as able. Private space is not used as general storage. Complete and continue with the work to refurbish bathrooms and WCs. (Previous timescale not met) Improve the access to the garden and make safe. (Previous timescale not met) Improve facilities for those with dementia i.e. signage, colours etc. (Previous timescale not met) Resite laundry facilities. The induction process must be to NTO guidelines. All care staff must receive supervision six times a year. Fire testing of alarms and DS0000029171.V258801.R01.S.doc Timescale for action 31/12/05 2 3 OP7 OP10 12 12 30/11/05 30/08/05 4 OP19 19 30/12/05 5 6 7 8 9 10 Holly Park OP20 OP22 OP26 OP30 OP36 OP38 19 23 13 12 18 13 30/12/05 30/12/05 30/12/05 30/11/05 28/02/06 02/11/05 Page 22 Version 5.0 emergency lights must be carried out weekly. Ensure that all wheelchairs are serviced. (Previous timescale not met) Safety checks of wheel chairs and bed rails must be carried out and recorded. (Previous timescale not met) With immediate affect as discussed. 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 3 Good Practice Recommendations To arrange for those carrying out pre admission assessment to be on duty on admission. Holly Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Park DS0000029171.V258801.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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