Inspection on 20/04/07 for Hollybank

This inspection was carried out on 20th April 2007.

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

Hollybank 27/04/06

Hollybank 24/01/06

Hollybank 29/09/05

Hollybank 24/09/04

Hollybank 22/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Hollybank 5 Abbots Lane Kenley Surrey CR8 5JB Lead Inspector Peter Stanley Key Unannounced Inspection 20th April 2007 9:30am 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 Hollybank DS0000025794.V336233.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 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. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank Address 5 Abbots Lane Kenley Surrey CR8 5JB 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) 020 8660 4213 020 8668 5087 Mrs Valerie Jane Taylor Mrs Valerie Jane Taylor Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 2006 Brief Description of the Service: Hollybank is a residential care home registered with the Commission for Social Care Inspections (CSCI) to provide personal care for up to seventeen older people. It is not registered to provide nursing care or dementia care. The home is a large detached domestic house providing 15 single and I double bedrooms. The home occupies a hillside site with sloping grounds to the front and back. The home has a single lounge and a separate dining room. The home has the usual facilities including toilets, bathroom (including assisted baths and a jacuzzi type bath) laundry, sluice, plus a kitchen and small office. This is an older property. The communal areas are not large but are homely and comfortable. The bedrooms with en suite toilets are very attractive. There are two bedrooms on the lower floor. These are large rooms and overlook the garden. The home has recently been renovated, with a new extension adding three en suite, single bedrooms to the home. There is a large patio area with outdoor furniture and a new outdoor decking area off the residents lounge. The registered provider and management team have made great effort to ensure refurbishment work to the home meets the Regulations and National Minimum Standards for the benefit of the service users. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the home took place over one day. Both the registered manager, Valerie Taylor, and the deputy manager, Debbie Barrett, were present during the course of the inspection, the deputy manager being principally involved in the detailed discussion of the relevant issues and standards discussed. The inspector toured the premises and spoke to a large number of residents, including one resident who has recently been admitted to the home, and to staff on duty. Care records and other documentation were examined, and the records of two recently admitted residents were casetracked. Of 14 requirements that were detailed in the last key inspection report, just one requirement, relating to the need for a legionella inspection and testing of the home’s water supply, remained outstanding from a follow-up random inspection on 10 November 2006. This has now been met. Of two new requirements that were made as a result of this visit, one remains outstanding. This relates to the need for the Development Plan to more clearly reflect outcomes for services users (as evidenced in feedback from surveys, care reviews and other sources) and the areas in which the home needs to consolidate and improve its operation. From this inspection there are two further requirements. These relate to the need for contracts to be issued to two new residents, and the need for all staff to receive updated training in adult protection and adult abuse. The inspector also makes four recommendations, two of which are carried over from a previous inspection. This includes the need for staff to be more involved in engaging residents in conversation, games and activities, and in providing some stimulation in their day. The inspector completed checks on staff and service users files. Two new service users have been admitted since the last inspection. Examination of their files indicated that full information regarding the referral and assessment of care and support needs, health care and personal details had been obtained, and that care plans and risk assessment had been appropriately completed and reviewed. A statutory care review is, however, required for one resident, recently admitted, who is currently in hospital. The inspector met with two recently admitted residents on his previous visit, and with another recently admitted resident on this visit. The feedback given indicated that the new residents are settling well in the home, and that they are generally feeling satisfied with the home and with the care and support being provided. The inspector also met with a number of other service users, both on this and the previous visit. Feedback was generally positive, with service users Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 6 indicating that they are happy with the home and that their needs are being well met by staff. No concerns were raised. The inspector has found Hollybank to be a pleasant and welcoming home, providing a congenial and homely atmosphere for its residents. The home is being run in an open and generally competent manner, and staff present as being caring and professional in their interaction with residents. The evidence from this and the previous inspections indicates that there has been a continuing improvement in the home’s operation and performance over the last year and that the home is providing a generally good standard of care and support. What the service does well: Residents are being provided with the information, which they require, to enable an informed choice as to where they would like to live. The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Residents are generally having their care needs reviewed so as to assess the suitability of the placement in meeting their needs. However, a review is required for one recently admitted resident once she has been discharged from hospital. Prospective service users, their friends and relatives are able to visit to assess the suitability of the home. Residents’ care plans, detailing their health, personal and social care needs (and how these are being met) are being drawn up with the involvement of service users and their relatives/representatives. These are being reviewed on a monthly basis. The home is ensuring that residents’ health care needs are being fully met. Residents are being protected by the home’s medication policies and procedures. Updated medication training for staff is planned. Residents are being treated with respect and their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 7 will be respected and that they and their family will be treated with care, sensitivity and respect. Residents are encouraged to maintain contact with their family and friends and to retain links with the local community. Residents are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. The meals provided are wholesome and appealing and are served at times, and in places, which are convenient for residents. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and residents and their relatives/friends are able to raise any concerns they may have. The legal rights of residents within the home are being protected and promoted. Residents are encouraged and assisted to vote if they wish. Residents are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home is in place for their protection. Residents’ rooms present as being safe, comfortable and pleasantly decorated, reflecting individual residents’ personal identities, and being suited to their individual needs. Residents have access to safe and comfortable communal facilities. Sufficient bathing, washing and toilet facilities are being provided for the home’s residents. Residents’ safety is being assured through the provision of sufficient aids and adaptations. Residents are living in a home that presents as being clean, pleasant and hygienic. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s residents. Residents are being safeguarded by satisfactory recruitment policy and procedures, and by the necessary recruitment and criminal records checks. Generally, staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. Updated training in adult protection is, however, required for all staff. The registered manager, with the support of the deputy manager, is managing the home in a caring, competent and responsible way. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 8 The financial interests of residents are being safeguarded by the home’s policy, procedures and practice. Residents can be assured that staff are being appropriately supported in meeting their needs. The interests of residents are being safeguarded by the home’s record keeping, with records being kept secure, up to date and accurate. The health, safety and welfare of residents and staff are being appropriately promoted and protected. What has improved since the last inspection? What they could do better: Generally, the home is demonstrating that it is meeting its aims and objectives and that it is being run in the best interests of service users. However, the home’s Development Plan needs to more clearly detail outcomes for residents, and highlight those areas where the home is doing well, less well or poorly. While there are occasional opportunities for residents to engage in recreational and social activities, these are not presently sufficiently varied or regular to fully meet their needs and interests. The home’s policies, procedures and practice are generally providing residents with protection from abuse. However, for residents to be fully protected, updated training in adult protection is required. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 9 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. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 10 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 Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are being provided with the information, which they require, to enable an informed choice as to where they would like to live. Residents are being provided with clarification of the terms and conditions of their placement, with a written contract. The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Residents are generally having their care needs reviewed so as to assess the suitability of the placement in meeting their needs. However, a review is required for one recently admitted resident once she has been discharged from hospital. Prospective service users, their friends and relatives are able to visit to assess the suitability of the home. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 12 EVIDENCE: A comprehensive Statement of Purpose and service user’s guide is in place. This is made available to all prospective and current service users. Both documents have been reviewed and updated, on 19.1.07 and 8.2.07 respectively. The inspector was informed that there have been two new admissions to the home since the last inspection. The files for the two individuals concerned were examined. The relevant care management assessments and care plans were evidenced, together with the home’s own assessments and risk assessments. One of the two admissions, who was referred by social services, was admitted to hospital after one month of residing in the home, and has not, as yet, had the opportunity for an initial statutory care review. This must be arranged as a priority once the resident has been discharged from hospital. The inspector spoke with a sizeable cross-section of residents during the inspection. This included one lady who had been recently admitted. She indicated that she had settled well since moving in, that she liked the home and her room, and that she felt well supported by staff. Other residents generally expressed a high level of satisfaction with the home and with the care and support provided. Residents view the management and staff as being generally respectful, caring and responsive in meeting their individual needs. This was supported by the inspector’s own observations during the inspection, interaction between staff and residents presenting as being generally caring and supportive. Both residents have not, as yet, had a formal contract put in place. One resident was admitted to hospital following admission and has not yet had the opportunity of signing a contract. A draft contract has been put in place for the other resident to sign once she has completed her six week trial period and had her review. Prospective service users are welcomed to visit the home and stay for a trial period if they wish before making a decision to stay permanently. Where a service user is unable to visit the home then a member of the staff will visit them to discuss a possible stay in the home. Unplanned admissions are avoided. The inspector has noted comments from visiting relatives and friends, which are generally very positive. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 13 Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care plans, detailing their health, personal and social care needs (and how these are being met) are being drawn up with the involvement of service users and their relatives/representatives. These are being reviewed on a monthly basis. The home is ensuring that residents’ health care needs are being fully met. Residents are being protected by the home’s medication policies and procedures. Updated medication training for staff is planned. Residents are being treated with respect and their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes will be respected and that they and their family will be treated with care, sensitivity and respect. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 15 EVIDENCE: The inspector examined a sample of care plans for a number of individuals living in the home. These are being maintained in separate files and provide considerable detail regarding service users’ assessed care and support needs. Care plans generally indicate the involvement of service users in developing them. There was evidence of care plan reviews taking place with care plans being updated and amended when necessary. Care plans are being reviewed on a monthly basis. Risk assessments are being carried out by the home as part of the Home’s assessment. The inspector examined a sample of care plans and risk assessments, including those of two recently admitted residents. These evidenced that there is detailed and comprehensive recording of individual needs, preferences and risks. The home also maintains a Personal Fact File for each resident. This is compiled with the involvement of the resident following their admission and provides details of individuals’ nearest relatives and contact details, a brief summary of the resident’s life history, details of their interests and beliefs, likes/dislikes, and preferred choice of food and drink. These are designed to assist in raising the awareness of staff to individuals’ life histories, needs and choices. The home is evidenced to be meeting the health needs of residents. Discussion with service users, and inspection of care plans and daily logs indicate that there is generally good practice in terms of identifying and meeting residents’ health care needs, and that individual needs are being identified and addressed. Service users’ records, and discussion with the deputy manager, indicate that where health concerns arise, these are being addressed. The inspector examined the accidents record (in which six accidents were recorded since the last inspection) and noted that appropriate actions, including seeking professional medical help, had been taken where there had been a fall or other accident had occurred. The home has generally developed good links with health care professionals, with periodic visits from a chiropodist, and access being arranged for local optician and dental appointments. District nursing is accessed as and when required. The home has, however, experienced difficulties, over the last year or so, with registering new residents with the existing GP practice. 10 of the Home’s 17 service users are registered with a local GP practice. The Deputy Manager has advised that the local GP practice no longer accepts any more than 10 registrations from the Home and that all other residents are being registered with two other local GP practices. As previously indicated by the Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 16 deputy manager, this situation is not ideal but is outside of the home’s control. Where individual concerns arise regarding GP cover the deputy manager is encouraging relatives to make representations to the FPC (Family Practitioner Committee). The home has sound policies and procedures in place for staff to follow to support safe medication practice. Blister packs are used and kept in a locked cupboard. The inspector examined medication profiles and medication administration (MARS) sheets; these were found to be in good order and appropriately maintained. No controlled drugs were in use at the time of inspection, but the provision of a locked cabinet within a locked cabinet was in place should service users require controlled drugs. It is the home’s practice for any staff member, undergoing training in this area, to regularly observe an experienced staff member administering medication; and once trained, to be observed administering medication by an experienced staff member, so as to ensure accuracy and safe practice. The home changed to a different pharmacy in 2005, due to deterioration in the quality of service provided by the previous pharmacy. Accredited medication training was last provided for all staff on 10/11/05 and has been scheduled to be updated. This needs to be prioritised. The inspector discussed medication practice with the deputy manager and recommends that there are two staff present for all administration of medication to residents, one to administer and one to observe to ensure accuracy. The evidence from this inspection indicates that the privacy and dignity of residents is being well respected in this home. The home has a Charter of Rights in place which outlines its obligations in respect of residents rights in regard to personal choice, privacy and decision-making, their right to being treated with dignity and respect, and rights in regard to undertaking activities/ risk assessment, and in maintaining a level of independence. A copy of the charter is provided to each service user. The inspector spoke to a cross-section of residents and received positive feedback. This indicated that staff are respectful and caring, and are sensitive to individual needs and privacy. Positive views were generally expressed regarding the caring attitudes of the home’s management and care staff, with residents feeling that their rights and privacy are being well respected. Service users are able, if they wish, to spend time in their own rooms during the day, and are able to have meals in their room if they so wish. Staff were observed to knock on residents’ doors before entering and to be respectful of individuals’ wishes and needs. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 17 The wishes of residents regarding the eventuality of their death are recorded on residents’ files, and religious and other beliefs regarding their death and funeral arrangements are respected. The home informs and involves relatives where potential life-threatening concerns arise. There have been two deaths at the home since the last inspection. From the discussion with the deputy manager, it was apparent that these events were dealt with in a caring and appropriate way, with the management and staff being respectful of other residents’ sensitivities. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While there are occasional opportunities for residents to engage in recreational and social activities, these are not presently sufficiently varied or regular to fully meet their needs and interests. Residents are encouraged to maintain contact with their family and friends and to retain links with the local community. Residents are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. The meals provided are wholesome and appealing and are served at times, and in places, which are convenient for residents. EVIDENCE: Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 19 The home provides a varied programme of activities. This includes weekly visits from musicians or entertainers, reminiscence therapy and bingo sessions. Activities include a regular weekly activities session, organised by a visiting group (Total Fitness), which includes activities such as exercises, quizzes, and games. Depending on the wishes of residents, occasional outings may be arranged to the theatre or concert hall. These have previously included outings to a pantomime or concert at the Fairfield Halls, though none have taken place in recent months. There are also occasional trips out for tea and shopping for those residents who are interested. A local residents association (in Kenley) arranges occasional social events and entertainment for residents and staff. This has included a recent Fish and Chip supper at the local Church Hall. At Christmas a party was organised for residents at the home. On the day of the inspection, however, there was little evidence of any organised activity, with a number of residents sitting in the lounge and presenting as largely unoccupied. One resident was knitting whilst two others were in conversation. The inspector recommends that staff give more attention to engaging residents in conversation, games and activities, and in providing some stimulation in their day. And that a daily activities log be maintained for this purpose. The home has its own Charter of Rights This details the home’s commitment to respecting choice and the personal autonomy of residents. Residents are encouraged to manage their own finances wherever possible. The inspector spoke with a number of residents regarding their daily lives in the home. Views expressed were generally positive with residents feeling that they had flexibility in their daily routines and were able to exercise choice in a number of ways, including where and how to spend their time, their choice of clothes and the layout of their rooms. Residents are able to take meals in their own rooms if they so wish. The atmosphere in the home is perceived to be open, welcoming and accepting of their individuality. Feedback given to the inspector indicated that the home is welcoming to visitors and that they are encouraged to maintain their contact with family and friends. While there is no separate room for receiving visitors, residents are able to receive visitors in their own rooms, or to go out with relatives or friends for tea or a visit somewhere. The food served at this home is generally good, with many favourable comments being received from residents. The food served on the day presented as being both tasty and nutritious. The registered person and staff are very committed to ensuring that service users received good wholesome meals. The home provides a choice of breakfast, a cooked mid-day meal and a lighter evening meal. Drinks are provided when required and snacks can be obtained upon request. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 20 There is a four weekly rotational menu within the home, which provides for a varied, wholesome and nutritious diet. The home has recently introduced a more varied lunchtime menu with two fresh main food options each day. There is also a choice of dessert. Meals are home cooked, with fresh vegetables, and are varied to provide choice and meet individual preferences. Any individual dietary requirements are recorded and catered for. A new system has been introduced whereby residents make their choices from the menu the night before or at breakfast. Meals are served in the communal dining room. This presents as being clean, homely and pleasantly arranged. Meals can, alternatively be taken in the resident’s own room, or in the lounge, if he/she so wishes. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 to 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and residents and their relatives/friends are able to raise any concerns they may have. The legal rights of residents within the home are being protected and promoted. Residents are encouraged and assisted to vote if they wish. The home’s policies, procedures and practice are generally providing residents with protection from abuse. However, for residents to be fully protected, updated training in adult protection is required. EVIDENCE: The home’s complaints policy meets the criteria required by this standard. This is available for residents, relatives and others, together with a copy of Croydon’s complaints procedure. A copy of the Complaints policy and procedure is kept near the front door, in the reception area, together with the home’s complaints and suggestions book. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 22 The inspector spoke with a cross section of residents. No concerns were raised, and feedback indicated that residents would feel able to raise any concerns that arise. There have not been any complaints made to the home since the last inspection. In keeping with a previous recommendation, the home maintains a record of any concerns or compliments, one concern having been noted since the last inspection. The registered provider facilitates monthly residents’ meetings, which assists in identifying any concerns that service users may have. The home aims to fully protect residents’ legal rights by involving family and friends in respect of their contracts, benefits and monies, and in attending reviews. The deputy manager has advised that the home does not act as an appointee on behalf of residents, but that where the resident is unable to manage his/her finances this responsibility is undertaken by a relative, solicitor or social services. Independent advocacy can be sought if a resident has no friends or family. The home maintains records of expenditure, with monies being reclaimed where appropriate. The deputy manager has previously advised that residents are enabled to participate in the civic process, being encouraged to vote in elections if they so wish. The deputy manager advised that no adult protection concerns have arisen within the last 12 months, none having been recorded. The home has an appropriate adult protection procedure in place, together with a copy of Croydon’s Adult Protection Policy and Procedures. There is also a ‘whistleblowing’ policy in place together with a copy of the General Social Care Council’s Code of Conduct for staff to reference. All staff undertake training in adult abuse and have received statutory adult protection training- on 27/2/06. There is, however, a need for all staff to receive updated training in adult protection and adult abuse. A requirement applies. The inspector spoke with a number of residents. Views expressed indicated that service users feel safe and secure within the home, and are able to express any concerns that may arise to the manager or deputy manager. No concerns were identified. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home is in place for their protection. Residents’ rooms present as being safe, comfortable and pleasantly decorated, reflecting individual residents’ personal identities, and being suited to their individual needs. Residents have access to safe and comfortable communal facilities. Sufficient bathing, washing and toilet facilities are being provided for the home’s residents. Residents’ safety is being assured through the provision of sufficient aids and adaptations. Residents are living in a home that presents as being clean, pleasant and hygienic. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home is a large detached domestic house providing 15 single and I double bedrooms. The home occupies a hillside site with sloping grounds to the front and back. There is a pleasant, large lounge and a separate dining room. The home presently has plans to redevelop the garden area and to make it more accessible for residents. A new small patio area is being laid down, with new garden furniture, and there are plans to build a conservatory (extending out from the annexe) for the benefit of residents. The inspector completed an inspection of the premises. Residents’ bedrooms present as pleasantly arranged and decorated, and personalised to reflect individuals’ identities and tastes. Each door has the name and a photograph of the resident on the outside, so as to ensure that both residents and staff are clear as to the occupant’s identity. Including the three rooms in the annexe, seven single bedrooms and the one double bedroom have ensuite washing and toilet facilities. The home has accessible toilets on all floors, with raised toilet seats and grab rails being provided to assist the service users. All toilet doors have been painted green with fluorescent green tape, and clearly labelled, so as to make them easily distinguishable. Washing and bathing facilities meet the individual needs of the service users. The home has had thermostatic valves fitted. These are set to ensure that the water temperature does not exceed 43 degrees C. Weekly checks of water temperatures in the home are being carried out, and recorded appropriately. The inspector spoke with a number of residents, most of whom were sitting in the communal lounge. Residents expressed their general satisfaction with the home and with the facilities provided. The inspector spoke with one recently admitted service user, who was in her room. She expressed her satisfaction with her room and with the home environment. Bath hoists, grab rails and raised toilet seats are present throughout the premises. The home has a call alarm system, which can be operated from all rooms within the home. The home was assessed by an occupational therapist in 2004, as a result of which grab rails on sections of the stairs, leading to the rear fire entrance, were put in. A stair lift was installed in 2005, this having been risk assessed for all residents who use this. This is being regularly serviced on a six-monthly basis, most recently on 2 March 2007. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 25 Heating, lighting and ventilation throughout the home present as satisfactory. Lighting is domestic in character and in keeping with the homely atmosphere. Most service users have table or wall-mounted bedside lamps. Fluorescent green tape has been affixed around all light switches in residents’ rooms so as to make these clearly distinguishable. The home presents as being clean and hygienic and to be meeting the necessary standards of cleanliness and hygiene. All staff at the home have been provided with infection control training, and clear guidelines in this area are in place. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s residents. Residents are being safeguarded by satisfactory recruitment policy and procedures, and by the necessary recruitment and criminal records checks. Generally, staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. Updated training in adult protection is, however, required for all staff. EVIDENCE: Staffing levels are being maintained in line with Care Home Regulations, and as appropriate to the number and assessed needs of the home’s service users. There are presently 14 care staff and four auxiliary staff, which includes two cleaners and two cooks. There are 15 residents, most of whom are physically Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 27 very frail and who have a range of associated disabilities. There are two vacancies. The staff levels on the day of inspection were generally observed to meet the agreed staffing levels. On duty were the registered manager, deputy manager, two care assistants, and an ancillary worker. The rotas indicate that staff levels are being maintained at the required level of 3 throughout the day on weekdays, and at weekends. Two staff are, however, presently on duty on the early evening shift from 4.45 to 9pm- it was confirmed by the deputy manager that this would revert back to three staff once the two vacancies have been filled. The staff rotas indicate that, for the overnight shift, there is one waking and one sleep-in staff member who are on call. Of 14 care staff, 7 currently possess an NVQ Level 2. The home is, therefore, just meeting the 50 target of staff with an NVQ Level 2. The home must, however, ensure that it remains on track for meeting and exceeding this target. The inspector has previously recommended that senior care workers at the home, including the staff member who is undertaking supervisory responsibilities, are enrolled for training leading to the NVQ Level 3.One senior care worker is currently studying for an NVQ Level 3. The inspector spoke widely with residents. Feedback received indicated that residents are generally very satisfied with the care and support that they are receiving from care staff, and feel that their individual needs are being appropriately met. No concerns were expressed. From his observations, the inspector found staff to be caring and attentive in their interactions with residents, The home has a training and development programme in place for which the deputy manager, Deborah Barrett, has been delegated responsibility. Records are in place for all staff training, and a rolling programme of staff training and refresher courses is available for all staff. This includes training in medication, adult protection, health and safety, manual handling, food hygiene and infection control. 3 staff members have completed emergency first aid, two as part of their NVQ2. Training in adult protection needs, however, to be updated, and training updates have been scheduled to take place in medication and a number of other areas. The home has an induction programme, which is currently being scheduled for review. The inspector examined the induction record of one staff member who was recruited just before the last (random) inspection in November 2006. This indicated that there had been a structured and ongoing programme of induction, and evidenced validated knowledge of the home’s policies, procedures and key areas of learning and practice. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 28 Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 29 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager, with the support of the deputy manager, is managing the home in a caring, competent and responsible way. Generally, the home is demonstrating that it is meeting its aims and objectives and that it is being run in the best interests of service users. However, the home’s Development Plan needs to more clearly detail outcomes for residents, and highlight those areas where the home is doing well, less well or poorly. The financial interests of residents are being safeguarded by the home’s policy, procedures and practice. Residents can be assured that staff are being appropriately supported in meeting their needs. The interests of residents are being safeguarded by the home’s record keeping, Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 30 with records being kept secure, up to date and accurate. The health, safety and welfare of residents and staff are being appropriately promoted and protected. EVIDENCE: The home’s registered provider is also the registered home manager; the deputy manager, Debbie Barrett exercises day-to-day responsibility for managing the home. She has, within the last year, completed studies for her NVQ Level 4 and Registered Manager’s Award. To help facilitate communication, a daily communications log is being maintained; this itemises issues and matters arising during each day. The deputy manager now receives periodic supervision from the home’s manager; this has assisted communication and enabled more effective management of the home. Communication and consultation between management and staff has also improved, with regular staff meetings taking place. Inspection of the staff meetings book indicated that staff meetings are now being held on a regular monthly basis. Full minutes of meetings are being recorded. The home has been developing its quality assurance processes. The deputy manager has advised that questionnaires have been compiled and completed with service users, relatives/friends, professionals, care managers and others visiting the home. A Development Plan has been put in place. This makes reference to good practice in terms of specific areas of practice and service user need. It sets out statements of intent but needs to be developed further so as to identify service user outcomes, and highlight those areas where survey and other feedback indicates that the home is doing well, less well or poorly. Or where newly identified needs exist. Objectives and priorities for the year ahead must also be identified. A requirement applies. The inspector was satisfied that service users’ financial interests are being appropriately protected. These are being safeguarded with records being kept of any expenditure on their behalf. Wherever possible, service users are encouraged to manage their own monies but, where not possible, relatives or external agencies such as social services or independent advocacy are invited to act on behalf of service users. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 31 The home no longer handles service users’ personal monies but keeps records of personal expenditure. These are billed monthly to the responsible relative or representative. The deputy manager has advised that any valuables entrusted for safekeeping are securely kept in the office within a lockable container. Receipts for any such item are issued in accordance with existing procedures, with a signed record being kept. The inspector examined staff supervision records and evidenced that staff have been receiving regular two-monthly supervision. The home is now ensuring that any new staff receive initial supervision within 2 weeks of commencing employment, and thereafter, on at least a monthly basis, for the first 3 months of employment. Following a recommendation from the last key inspection, some delegation of the supervisory workload to a senior care worker has been taking place. This has assisted in enabling regular staff supervision to take place. Staff are being annually appraised. Inspection of a sample of staff files indicates that annual staff appraisals were last completed on 20.4.06. Generally, the interests of residents are being safeguarded by the home’s record keeping, with records being up to date, accurate and securely stored. All records that are required for regulation are in place and are maintained to a high standard. The records that were inspected included staff and service user files, medication charts, accident and incident records, complaints records, and staff rotas. The inspector was generally satisfied with the home’s upkeep of its records, these being maintained in reasonably good order. Following a recommendation from the last key inspection, new files for residents have been developed, with a front index and separate sections for service user information, assessments, care plans, health, medication, record of accidents and incidents, activity charts, and daily care notes. These are providing a more structured and orderly storage of information. On his previous visit, on 10.11.06, the inspector examined a sample of the home’s policies and procedures and evidenced that these had been reviewed on 16.5.06. The deputy manager advised that all of the Home’s policies and procedures had been reviewed on this date, with updating taking place where required. Further review is due in May 2007. The inspector completed an inspection of the premises and requested documentation regarding health and safety, and fire safety checks. The health, safety and welfare of service users and staff are evidenced as being appropriately promoted and protected. The premises present as generally wellmaintained and no specific concerns were identified. Health and safety risk assessments for the home have been updated (on 7/10/06), and the Fire Risk Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 32 assessment updated (on 21/8/06). A new Fire Risk assessment is due to be undertaken on 23 May 2007, together with fire safety training for all staff. The inspector completed checks on servicing, maintenance and safety. These included servicing of the gas boiler and supply (last serviced on 26/3/07), legionella inspection for the home’s water storage has now been completed (27/2/07), electrical portable appliances (23/11/06), stair lift (2/3/07), manual and bath hoists (23/9/06). An electrical installation inspection is now due, and has been arranged. The home’s emergency lighting, nurse call alarm system and fire alarms are being tested 3 monthly, most recently on 21/2/07. Fire extinguishers were last tested on 7/7/06, and fire drills are being held on a two-monthly basis. Weekly fridge and freezer checks are being completed, together with weekly water temperature checks. Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 33 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 3 3 Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 34 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 OP18 Regulation 13(6) Requirement The registered manager must ensure that all staff receive updated training in adult protection and adult abuse. The registered manager must ensure that the Home’s Development Plan is revised so as to highlight the key outcomes for service users as evidenced from surveys and other feedback. The Plan must also provide an assessment of the Home’s performance in meeting service user needs, and in fulfilling its stated aims and objectives. Objectives and priorities for the year ahead must also be identified. Timescale for action 30/09/07 2 OP33 24(1-3) 31/05/07 Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 35 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 OP27 Good Practice Recommendations The inspector recommends that senior care workers at the home, including the staff member who is undertaking supervisory responsibilities, are enrolled for training leading to the NVQ Level 3. This will assist in developing their knowledge and skill base for the benefit of both the home and its’ service users, and assist in furthering their professional development. Accredited supervision and appraisal training should be accessed for the senior care worker with supervisory responsibilities. The inspector recommends that there are two staff present for all administration of medication to residents, one to administer and one to observe to ensure accuracy. The inspector recommends that staff give more attention to engaging residents in conversation, games and activities, and in providing some stimulation in their day. This should be recorded on a daily activities log. 2 OP36 3 OP9 4 OP12 Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI Hollybank DS0000025794.V336233.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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