Inspection on 21/06/07 for Hollybank

This inspection was carried out on 21st June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hollybank 07/11/06

Hollybank 24/01/06

Hollybank 29/07/05

Hollybank 03/03/05

Hollybank 02/08/04

Similar services:

Thornton Lodge

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Hollybank 27 Park Road Southport Merseyside PR9 9JL Lead Inspector Mrs Claire Lee Key Unannounced Inspection 09:00 21st June 2007 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 DS0000017242.V334388.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 DS0000017242.V334388.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank Address 27 Park Road Southport Merseyside PR9 9JL 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) 01704 530748 Mrs Ann Mallinson Mrs Ann Mallinson Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16), Terminally ill (2) of places Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 16 OP and up to 2 TI Date of last inspection 7th November 2006 Brief Description of the Service: Hollybank is a privately owned Care Home providing nursing care for sixteen older people. The Registered Provider and Registered Manager is Mrs Ann Mallinson. Accommodation at Hollybank comprises of ten single bedrooms with one ensuite and three double bedrooms with one en suite. Hollybank is situated in a quiet residential area of Southport close to the town centre, local amenities, the beach and Hesketh Park. The home consists of a four-storey building with a large garden at the front and small patio to the rear. The home has a passenger lift and there is wheelchair access to the front door. Residents have the use of a call bell with an alarm facility and there is equipment in place to assist those who are less independent. The fee rate is set at £463.50 a week for accommodation. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection. It was conducted over one day for duration of eight hours. Thirteen residents were accommodated at this time. A partial tour of the premises took place and a number of the home’s care, staff and health and safety records were viewed. Discussion took place with seven residents, four staff, two relatives and the registered manager. During the inspection two residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. All the key standards were inspected and also previous requirements and recommendations from the last inspection in November 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents prior to the inspection and one was left for a health care professional to complete at the time of the visit. Comments included in the report are taken from the resident survey forms and also during the site visit. What the service does well: Hollybank presents with a very warm, caring and friendly environment. Residents appeared comfortable in their surroundings and staff were observed spending a great deal of time with them either on an individual basis or within a group. Care was seen to be given in a discreet manner and staff were patient and gentle in their approach. Feedback from residents and relatives was good regarding the service, comments included: “A lovely home” “You could not have a better home” “Just lovely staff” “A good home” (relative) The daily routine is based around residents’ wishes where possible and this was noted in relation to the time baths were offered and also the time residents like to go out from the home. A resident said, “I go out most days and I decide what time is best for me”. Visitors were seen popping in at various times and a relative reported that staff were always cheerful and very polite. Refreshments were offered to visitors. Residents reported that they were pleased with the care and the assistance provided by staff. Those interviewed stated that there was a good number of Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 6 staff on duty and that their calls for assistance were answered promptly. A resident said, “I ring the bell and the girls come straightaway”. Basic care needs are identified in an individual plan of care and the resident and/or their relative had been approached for their consent. Care documentation had been reviewed regularly to ensure the information was up to date and relevant. An activities co-ordinator arranges a good social programme for the residents and this includes, cards, bingo, manicures, massages and quizzes. Several ladies commented on the fact that they enjoy the manicures and also the regular visits from the hairdresser. Social arrangements are recorded in a book and a social profile is completed for each resident in their care file. This provides detail of the residents’ preferred interests and social background. Feedback from residents is welcomed when arranging different events. Residents interviewed were pleased with the food and the choice offered at each meal time. There is no dining room however residents are served their meals in the lounge or in their rooms if preferred. A small menu board displayed the main meals of the day. A resident said, “The food is just great and whatever I want the manager gets for me”. Staff were observed to offer assistance to residents with their lunch in a discreet manner. Hollybank provides a ‘homely’ lounge with comfortable furniture. A resident commented on the fact that the room is just like being in your own front room and that it does not feel like a nursing home. Bedrooms seen had been personalised by the residents with items from their own home. Two new staff require moving and handling training however the manager has an ongoing training programme with external trainers and staff said that they attend regular courses. Residents’ views of the service are obtained via surveys, which are sent out as part of the annual external quality award. What has improved since the last inspection? What they could do better: Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 7 The manager completes a care need assessment prior to a resident taking up residency. Further detail should be recorded in certain areas, for example, mobility, where an assessment indicates that staff will need to offer a higher level of assistance due to the resident’s condition and the risk of falls. Care plans seen were satisfactory but with further details recorded at the time of the assessment staff will have more knowledge to write a more detailed plan of care. This was discussed in relation to moving and handling and how to further develop risk assessments with the preventative/control measures. The majority of residents are frail in health and are unable to be weighed. Girth measurements are recorded to monitor weight gain or loss however one new resident had not had a baseline girth measurement recorded. This was brought to the manager’s attention. Recruitment of staff was not robust to protect the residents. One staff file evidenced that a staff commenced employment prior to a POVA (Protection of Vulnerable Adult) check had been obtained. A POVA and/or CRB (Criminal Record Bureau) enhanced disclosure must be obtained prior to starting work to protect the residents from potential harm or abuse. Two new staff require training in moving and handling to ensure they are skilled and competent to move residents safely. They are currently working with senior member of staff and are not left when transferring residents. The manager stated that she has not held a staff meeting for a long time and minutes of the last meeting could not be located. A staff meeting should be held to enable staff to get together and discuss general issues regarding the overall management of the service. A number of staff have also signed a disclaimer to say they do not wish to have formal supervision. The manager supervises staff on a daily basis however there should be some written record to evidence this. 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 DS0000017242.V334388.R01.S.doc Version 5.2 Page 8 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 DS0000017242.V334388.R01.S.doc Version 5.2 Page 9 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): Standards 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information regarding the service and the manager completes a pre admission assessment for residents. This ensures that staff can meet their health and social care needs. EVIDENCE: A copy of the statement of purpose and service user guide was seen in the office and a relative confirmed that they received this information to help them choose accommodation suitable for their family member. These documents should be placed on display in the main hall for residents and relatives to view. The manager stated that there have been no changes to the service and therefore the information remains unchanged. Assessments were viewed for two new residents and these are carried out by the manager with as much input as possible from the resident, their family or representative and any other health care professionals involved in their care. A care assessment from social services was available in one file and a transfer letter from a local hospital in another. This information assists staff with Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 10 collating resident details to ensure they can provide the care and support required. The pre-admission assessment covers all the relevant key areas, for example, mobility, personal hygiene, medical history, continence, risk of falls, care of skin, social/family background, sleeping and diet. Residents are also asked about their sight, hearing and dental needs, which are so important to the care of the older person. Cultural requirements are assessed as part of this process to enable staff to be aware of diverse needs. It would be beneficial to record further details regarding moving and handling where a potential risk has been identified. This would provide staff with more information regarding how to transfer the resident safety with the necessary equipment. A monthly assessment with a dependency scoring system is completed and reviewed each month as part of the plan of care to ensure care needs have been accurately assessed. A resident confirmed that they had been made welcome by all the staff when they arrived at Hollybank and that although it was not like their own home they were settling in gradually. The manager encourages prospective residents and their relatives to visit the home as often and as for as long as they wish. Standard 6 was not assessed, as intermediate care is not provided at Hollybank. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs were identified in a plan of care and medicines were administered safely to them. Residents were observed to be treated in a respectful manner. EVIDENCE: As part of the case tracking process the care files for two new residents were viewed. These included residents of varying ability and needs. Residents have an individual care file and the information seen was easy to read and made available for staff and residents. Care documentation had been reviewed regularly to ensure the information was relevant and accurate. Consent and agreement to the care plan by the resident and/or their relative had also been obtained. Care plans identified key areas in health and social care, including personal care, diet, mobility, falls, continence and social involvement (social profile is completed for this purpose). The use of equipment, for example, an air mattress had been identified in one moving and handling assessment and recorded in a plan of care. The resident confirmed that the mattress was put in place immediately and was providing the required relief. It is recommended that the moving and handling assessment should include further detail regarding any potential risk or factors that affect a resident’s mobility. The Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 12 number of carers involved in a transfer should be recorded to ensure the correct number of staff undertake the move safely. The plan of care needs to be then updated with this detail to ensure the care provision is made known to all staff. Supporting documentation including risk assessments for care of skin, use of bed rails, nutrition and risk of falls. Advice was given to the manager on how to develop risk assessments, as examples viewed had limited information on the preventative/control measures. The term ‘cot side’, which is recorded in care files, should be replaced with the term ‘bed rail’ as this is more appropriate language. Residents have their weight monitored to record weight gain or loss either by use of scales or a girth measurement. One new resident had no weight record on file and the manager was advised that a girth measurement should be recorded for this purpose. Health checks of blood pressure are also undertaken as part of the ongoing care provision. Daily report sheets recorded the day given over a twenty four hour period by the staff. Care staff have a key worker role, which enables them to take on more responsibility for a set number of residents. Staff interviewed said they enjoyed this role. Two new residents require photographs to be taken for identification purposes and the manager stated that this would be carried out. Evidence was seen that residents are referred to relevant services such as GP’s and a chiropodist in a timely and effective manner. A resident interviewed confirmed that she saw her dentist and optician regularly. Feedback from the survey forms received and discussion with residents at the time of the site visit was good. Residents interviewed were very pleased with the level of care and support provided by the staff. Comments included: “Very good care” “Lovely staff” “Could not have better attention” Medicines were being administered safely to the residents. The medicines were stored appropriately and administered from bottles dispensed by a local pharmacist. Medication Administration Records (MAR) viewed had been correctly completed to record the details of medication received and administered in the home. A resident confirmed that they received their medicines on time and suitable systems had been established to account for medication returned to the pharmacist. Staff have the use of medicine reference books however a copy of the guidelines issued by the Royal Pharmaceutical Society of Great Britain would be beneficial. This was obtained via the Internet at the time of the site visit. Leaflets were available of medicines currently being administered for staff referral. There were no Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 13 residents who wished to administer their own medicines at this time. Advice was given to the manager on how to further develop the risk assessment for people who wish to self-administer thus providing more detail of the assessment, monitoring and review processes. An audit trail of two medicines confirmed that they had been given according to the prescription. The medicine Temazepam, which is a medicine liable to misuse, had been recorded in the controlled drug register and administered by two staff members. Resident and relatives interviewed stated that they were treated in a respectful manner and a new member of staff confirmed that respecting a resident’s right to privacy and dignity was discussed when they starting their induction. Staff were observed to knock on doors before entering private rooms and assisting residents with their meals in an unhurried manner. All residents appeared smartly dressed and screens were available in the double rooms to ensure individual privacy. A resident said, “The girls are very polite indeed”. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise choice and control over their lives and are offered a choice of well balanced and nutritional meals. EVIDENCE: Hollybank has a very warm, welcoming atmosphere and a good rapport was noted between the staff, residents and their visitors. Discussion with the manager and residents confirmed that activities are arranged three afternoons a week. The appointment of an activities co-ordinator has seen the introduction of a programme of social interests. A record of the residents’ involvement was seen. Three residents said that they enjoyed everything that was arranged and one resident although being nursed in bed said that they receive, “One to one activities in my room like manicures and massages when I feel like it”. Activities include, massages, manicures, quizzes, bingo, card games and walks in the park during the warm weather. Residents are asked if they would like to be the bingo caller and one resident attends bingo mornings in Southport. A hairdresser visits the home once a fortnight and one resident had her own private hairdressing visiting at this time. Links with the local community are in place, one resident is attending the stroke club and religious ministers of various denominations visit a number of residents on a regular Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 15 basis. Residents are able to receive Holy Communion. One resident said church members come to see her regularly. Residents spoken with confirmed that they were happy with the routine and that staff did not mind what time they went to bed or got up in the morning. A resident said that they go out regularly with a family member and the staff are obliging in sorting out the arrangements. Staff were observed to offer residents a bath in the afternoon if preferred. Residents had personalised their rooms with pictures and personal possessions and friends and relatives were observed to visit residents throughout the day in the lounge or in the privacy of their own bedroom. The daily menu is displayed in the lounge for residents to choose what they would like to eat. The menu is based over two weeks and residents are offered wholesome nutritious meals. The cook takes on board suggestions from the residents as to the meals they would like and an alternative is available at each mealtime. The main meal is served at lunch time and a lighter meal in the evening. Meals are served in the lounge as there is no dining room or residents can have their meals in the rooms if preferred. Lunch was not hurried in any way and the trays were attractively laid with matching crockery. The kitchen is domestic in style but is well equipped and meals are served from a heated trolley. The cook had completed a copy of the safer food better business manual, supplied by an Environmental Health Food Safety Officer; records seen were current. A staff member said that whatever the resident wants, the manager will buy and ensure it is to their liking. In the past meals from different countries have been cooked however at this time the residents prefer good home English cooking. Comments from the residents regarding the food include: “Good choice of food” “Nicely served lunch” “Fresh vegetables are given to us” “I have no complaints about the cooking” “Very good cook” The kitchen and food stores were examined and found to be clean and well stocked with supplies. Residents confirmed that they have fresh fruit and vegetables. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polices and procedures are in place to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: Hollybank has a complaints policy, the details of which are included in the home’s statement of purpose and service user guide. A copy of the complaint policy was on display for residents and relatives to view. Staff interviewed were aware of the policy and stated that they would report any concern to the nurse in charge and/or the manager. Discussion with the manager and information provided as part of the pre inspection questionnaire confirmed that no complaints have been received ‘in house’ or to the Commission. Staff have access to a policy on abuse and also Sefton’s Guide to the Protection of Vulnerable Adults (POVA). A training record evidenced that POVA training is provided routinely for staff members and three staff interviewed discussed whistle blowing and what constitutes abuse. One person lacked awareness of the adult protection team and this was brought to the manager’s attention as a training issue. This should be arranged as soon as possible to clarify the issue raised. Resident financial records seen were up to date and evidenced staff signatures and balance totals to protect the residents’ finances. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 17 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): Standards 19,21,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well maintained, pleasant, comfortable home. EVIDENCE: Hollybank is a detached older style property that provides comfortable, clean accommodation. Residents interviewed said that they like the feel to the place as it reminds them of their own private home and is not like a nursing home. General maintenance is carried out by the manager’s husband and external contractors are brought in when need. There is ramp to the front door for wheelchair access and the front garden has seats for the residents to use in the warm weather. The garden is attractively landscaped. There is a small enclosed area at the rear though generally the front garden is used. A full health and safety check and maintenance report is carried out of the building every six months and any work required identified and actioned. Bedrooms seen were pleasantly decorated and residents had brought in items from home. A resident said that they liked their room and that it had Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 18 everything they needed. Paint work outside Room 6 is badly scuffed and the manager said that this area is due to be painted as the hoist causes the damage. A tap needs to be replaced in this room also as it is broken. Bedrooms are fitted with a call bell and a resident said that when they need the staff, “I just call out”. Staff were observed to answer calls for assistance promptly. Emergency lighting is provided throughout the building and subject to an in house monthly test and an annual safety check by an external contractor. A separate record should be kept of the monthly emergency lighting check as although it is carried out it is recorded under the fire alarm record. Staff test the temperature of the hot water to the bath to ensure it is delivered to a safe temperature. Records seen were satisfactory. The bathroom on the ground floor is used as this provides more space for the staff to bath residents comfortably. For the purpose of reducing cross infection paper towels should be made available for hand drying. The manager confirmed that these would be put in place or disposable wipes made available as these are used by staff in other areas. The bathroom is equipped with a bath hoist to assist those less able. The laundry room is equipped with an industrial washing machine and dryer and the care staff attend to the laundry on completion of their care duties. Staff had access to gloves and aprons, which were being used at the appropriate time. Residents spoken with confirmed that the home was always kept clean and fresh. Likewise a relative reported, “It is a nice home to walk in to and always smells clean”. This was evidenced at the time of the site visit. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practices are not robust to protect the residents and some staff have not completed the necessary training, to confirm they are competent to undertake their roles effectively. EVIDENCE: The staffing rotas detailed that there are sufficient numbers of staff on duty to provide care and support to the residents. The level of staffing is sufficient to allow for a good level of interaction between staff and residents and for care delivery to be carried out in a calm and unhurried way. The manager stated that agency staff are only used in an emergency, existing staff cover any outstanding shifts. There is a fairly low turnover of staff however two new care staff have been employed since the last inspection. The staffing rota is organised so that an over lap of staff occurs in the afternoon and staff interviewed said that the manager never allows the staffing numbers to fall. The deputy matron was in charge at the time of the site visit and was supported by a full compliment of staff. The manager was off duty but attended the inspection. Residents spoken with confirmed that staff were always available when required to assist them with personal care and day-to-day activities. This was discreetly observed in practice. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 20 The deputy matron is undertaking NVQ Level 4 in Management and NVQ training is ongoing for care staff. NVQ records were seen for two members of staff however not all files had certificates in place and the manager was asked to remind staff to bring these in for the purpose of updating their training records. The pre inspection questionnaire evidenced that 60 staff have achieved an NVQ qualification in care at Level 2/3. The cook on completion of working in the kitchen undertakes domestic duties and care staff assist with tidying bedrooms. Three staff files were viewed for the purpose of ensuring residents are protected by the recruitment policy; this included staff files for two new employees. Documents showed one instance of a member of staff starting work before POVA First clearance and/ or CRB (Criminal Record Bureau) enhanced disclosure clearance being obtained. The manager was advised that no new member of staff must be allowed to commence employment before the clearance is obtained and then will be required to work under supervision until the full Criminal Records check is received. Failure to comply will result in residents being placed at risk and the Commission taking appropriate action to ensure compliance. One staff file only had one reference however a second reference was faxed through from a named referee at the time of the site visit. A photograph is also required for two staff for verification purposes. Recruitment practices must be improved to ensure the ongoing protection of the residents. The files had completed application forms and staff confirmed that they received job descriptions. There was evidence of staff contracts on file. New staff receive an induction however it is recommended that the induction be given in more detail and in line with Skills for Care induction standards. This will provide staff with more detail regarding care practices and assist with NVQ awards. New staff interviewed stated that they were shown round the premises when they started and worked with a senior member of staff. Due to the size of the registration the manager employs a small team of staff however training in safe working practice areas is accessed via an external training company. A training record evidenced that staff receive training in first aid, moving and handling, fire safety, infection control, food hygiene and POVA. Two new staff require moving and handling training to ensure they have the skills and knowledge to transfer residents safely. Infection control, food hygiene and POVA were given to a number of staff in May 2007. Fire training is next planned for November 2007. Training includes specialist areas such as dementia and palliative care at the hospice. The training record evidenced the month of the training; the actual date the training took place should also be recorded to maintain the accuracy of the record. Comments from the residents and relatives regarding the staff include: “Very good staff” Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 21 “Pleased with the staff (relative) “Good staff” ”Very helpful indeed” (relative) “There are good staff” Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 22 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): Standards 31,32,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs a manager who is experienced and qualified to manage the service effectively and who seeks the views from the residents to provide a quality service. Policies, practices and procedures are in place to safeguard the health, welfare and safety of residents and staff. EVIDENCE: The manager, Mrs Mallinson lives on the premises and is the registered owner. Mrs Mallinson is a registered nurse who maintains her registration with the NMC (Nursing Midwifery Council) and is very involved with the day to day running of the home. Mrs Mallinson assists care staff with their duties, acts as a key worker and cooks for the residents on a Sunday. Residents, relatives and staff were very complimentary regarding here professionalism and her kind, caring approach. A resident said, “Anne (manager) is just lovely”. Likewise another resident said, “The home is really good and I would recommend it to Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 23 any one”. Mrs Mallinson’s management style is open and transparent as evidenced in conversations with staff, residents and relatives whilst maintaining a focus on managing the service in the best interests of people who require a high level of care and support. Mrs Mallinson sees the establishment of an effective quality assurance system as a key part of her role by commissioning an external consultant to undertake an annual quality assurance assessment. The most recent rating was issued to the home in December 2006. As part of the external award, resident views are sought via surveys and a summary for the findings for 2005 was seen. This evidenced satisfaction for the service; the summary for 2006 was not available. Resident meetings are not held as there are only a small number of residents and they have not proved successful in the past. Mrs Mallinson meets with the residents each day and those interviewed confirmed that they would speak to her if they wished to bring something to her attention. Obtaining the views of staff should also be encouraged as part of the quality assurance process. Minutes of the most recent staff meeting could not be found and the manager stated that meetings are not held regularly as not all staff attend. Staff meetings should be held to discuss the overall management of the service. Staff supervision has also been declined by a number of staff who have signed to stay they do not wish to take part in these sessions. Evidence was seen of this in a number of staff files viewed. Mrs Mallinson stated that she supervises the staff on a daily basis and handovers are given at each shift change with regards to advising staff of the care needs of the residents. It very strongly recommended however that there be some written evidence to support the supervision for staff. This should be given on an individual or group basis. Two staff appraisals were seen for 2006 however the manager stated that a number of staff require their appraisal for 2007. Staff have access to a good number of policies and procedures and these are updated when required by the external consultant who undertakes the annual quality assurance award. The policies for abuse, confidentiality, privacy and dignity were viewed. Staff interviewed confirmed that they were made aware of the policy folder and its contents during their induction. Regulation 26 visits are not conducted as Mrs Mallinson is the registered owner and also lives on the premises. Mrs Mallinson is in daily attendance to monitor the service. The manager is currently looking after finances for two residents. Records checked were up-to-date, receipts had been obtained and balances were correct. Pre-inspection records detailed that equipment within the home was regularly inspected and serviced. A spot check was undertaken for the gas, electric, Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 24 clinical waste disposal, hoist, lift and testing of portable appliances. Certificates seen were found to be valid. Fire records were examined. Records confirmed that the fire alarm system was tested on a weekly basis and a certificate was in place to confirm the emergency lights, fire extinguishers and fire alarm system had been serviced. Staff receive fire prevention training as part of their induction and also on a regular basis by an external company. This was last given to staff in November 2006. Staff on duty receive fire instruction when the alarm is tested each week however fire safety recommend that fire instruction be given to all staff every six months. This is to include the night staff who do not attend the instruction when the alarms are tested during the day. Evidence was seen of a fire risk assessment of the premises and the manager stated that an external company are due to visit to conduct a review of the assessment. This will ensure it is compliant with the changes to the fire regulations. The accident book is kept in the staff office and this evidenced accidents or incidents that affected a residents’ well being. Only two new staff require moving and handling training and the manager stated that this would be arranged as soon as possible, this is stated under Standard 30 of this report. Equality and diversity is addressed throughout the care planning process and residents’ cultural requirements and wishes are discussed on admission. This ensures staff have a good knowledge of individual needs. Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP27 Regulation 19 Schedule 2 - 7. Requirement The registered person shall not employ a person to work at the care home unless they have obtained the necessary police checks. The manager must ensure that a member of staff only commences employment pending receipt of a CRB if a full and satisfactory POVA check has been received. Persons working in a care home must have a photograph for proof of identity. The manager must obtain a photograph for this purpose from two new staff. The registered person must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. The manager must ensure new staff receive moving and handling training to ensure they have the skills and knowledge to transfer residents safely. Timescale for action 14/07/07 2. OP27 Schedule 2 – 1. 14/07/07 3. OP30 18 (1) (c) 21/08/07 Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 27 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. 2. Refer to Standard OP1 OP3 Good Practice Recommendations The statement of purpose should be displayed for residents and visitors to view. Details of moving and handling should be recorded in more detail as part of the assessment where a potential risk has been identified. The moving and handling assessment and plan of care should include more detail regarding any potential factors or risks that affect the resident’s mobility and instructions to staff with regard to number of carers to assist with transferring a resident. If a resident is unable to be weighed a girth measurement should be recorded to monitor weight gain or loss. Staff should receive training in adult protection to ensure residents are safeguarded from abuse. A separate record should bed kept of the emergency lighting checks that are undertaken each month. Paper towels for hand drying should be place in the ground floor bathroom to reduce the risk of cross infection. Skill for Care induction standards should be implemented for new staff as part of the induction process. Staff meetings should be held to discuss the overall management of the service. Staff should receive supervision as part of their ongoing development. Fire training should be given to all staff every six months. 3. OP7 4. 5. 6. 7. 8. 9. 10. 11. OP8 OP18 OP25 OP26 OP30 OP33 OP36 OP38 Hollybank DS0000017242.V334388.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 DS0000017242.V334388.R01.S.doc Version 5.2 Page 29 - 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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