Inspection on 27/04/06 for Hollybank

This inspection was carried out on 27th April 2006.

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

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

Other inspections for this house

Hollybank 20/04/07

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 27th April 2006 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.V291829.R01.S.doc Version 5.1 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.V291829.R01.S.doc Version 5.1 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.V291829.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 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.V291829.R01.S.doc Version 5.1 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 service users, including two who have been recently admitted to the home, and to staff on duty. Care records and other documentation were examined, and the records of four recently admitted service users were casetracked. As a result of this inspection, there are 14 requirements, 5 of which have been carried forward from the previous inspection. The time-scale for unmet requirements are shown in bold italics. Three recommendations also apply. The inspector has found Hollybank to be a good home, providing a congenial and homely atmosphere for its residents. The home is being run in a caring, open and generally competent manner. From the evidence of this and previous inspections, the inspector has been gratified by the receptivity of management to embrace change and to look at raising standards across the board. The staff at the home are generally liked and well-regarded by the service users, and are observed to demonstrate a professional and caring approach in the performance of their duties. The home has, over the last year, built upon improvements in certain key areas, notably in its recruitment practice and procedures, its assessment of service users, care planning, and staff training. From this inspection, there were a number of health and safety concerns which were identified, and a continuing concern regarding the maintenance of adequate staffing at weekends. Staff appraisals must be completed annually and policies and procedures reviewed twelve-monthly. These issues must be addressed as a high priority. The inspector would like to extend his thanks to the registered manager, Valerie Taylor, and the deputy manager, Debbie Barrett, for their assistance with the inspection, and to extend his thanks to both staff and service users for their cooperation and the views expressed. What the service does well: Service users are being provided with the information, which they require, to enable an informed choice as to where they would like to live. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 6 Generally, the home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their friends and relatives are able to visit to assess the suitability of the home. Service users’ 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 service users’ health care needs are being fully met. Service users are being treated with respect and their right to privacy is being maintained. Service users are being provided with opportunities for recreational and social activities sufficient to meet their existing needs. Service users expressed their satisfaction with the range of activities provided. Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Service users 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 to them. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are able to raise any concerns they may have. The legal rights of service users within the home are being protected and promoted. Service users are encouraged and assisted to vote if they wish. Service users 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. Service users’ rooms present as being safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Service users have access to safe and comfortable communal facilities. Service users presented as very satisfied with their environment. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 7 Sufficient bathing, washing and toilet facilities are currently in place. The home has been assessed as safe to meet the needs of service users, providing sufficient aids and adaptations. Service users live in a home that presents as clean, pleasant and hygienic, and in which staff’s awareness of hygiene issues and practice has been raised through infection control training. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home is on track for meeting the target of 50 of staff with NVQ Level 2. Staff are generally being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of service users. Service users’ financial interests are being safeguarded by the home’s policy, procedures and practice. The interests of service users are being safeguarded by the home’s record keeping, with records being secure, up to date and accurate. What has improved since the last inspection? Service users are being protected by the home’s medication policies and procedures. All care staff have recently completed accredited medication training. The home’s policies, procedures and practice are providing service users with protection from abuse. All care staff have recently completed statutory adult protection training. Service users are generally being safeguarded by satisfactory recruitment policy and procedures, and the necessary recruitment checks. The home is now ensuring that CRB (Criminal Records Bureau) checks are completed prior to commencing the employment of any new staff. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 8 What they could do better: Generally, service users are being provided with clarification of the terms and conditions of their placement, with a written contract; however, one service user (admitted on 17/11/05) has yet to receive one. While service users are generally having their care needs reviewed, one service user (admitted on 17/11/05) has not, as yet, had an initial statutory care review to assess the suitability of the placement in meeting her needs. While, generally, service users’ needs are being met, there are, at times, an insufficient number of staff on duty to ensure that there is adequate support available. This presents a potential risk to the welfare and safety of service users and must be rectified. The registered manager, with the support of the deputy manager, is managing the home in a caring and responsible way. The management of the home needs, however, to demonstrate (with a Development Plan) that it is meeting its aims and objectives and that it is being run in the best interests of service users. With regular, one-to-one supervision now being provided, service users can generally be assured that staff will be appropriately supported in meeting their needs. However, for sufficient protection to be in place, new staff members should receive more frequent supervision in the early months of their employment, and all staff should be annually appraised. To provide sufficient protection for service users, the home must ensure that all of its policies and procedures are reviewed at least annually. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected; however, for service users and staff to be assured as to their safety, the home has to demonstrate that it is complying with all health and safety, and fire safety requirements. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 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. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 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.V291829.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 5 Service users are being provided with the information, which they require, to enable an informed choice as to where they would like to live. Generally, service users are being provided with clarification of the terms and conditions of their placement, with a written contract; however, one service user (admitted on 17/11/05) has yet to receive one. Generally, the home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. While service users are generally having their care needs reviewed, one service users (admitted on 17/11/05) has not, as yet, had an initial statutory care review to assess the suitability of the placement in meeting her needs. Prospective service users, their friends and relatives are able to visit to assess the suitability of the home. EVIDENCE: Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 12 A comprehensive Statement of Purpose and service user’s guide is in place. This is made available to all prospective and current service users. The inspector was informed that there have been four new admissions of service users to the home since the last inspection. The service users’ files were examined. The relevant care management assessments and care plans were evidenced, together with the home’s own assessments and risk assessments. Risk assessments had been completed for two admissions, but remain to be completed for two very recent admissions (on 22/3/06 and 21/4/06). A requirement applies. One service user, admitted on 17/11/05, has still not, as yet, had an initial statutory care review following their admission; the deputy manager informed the inspector that there has been no contact from the relevant funding authority, to arrange a review. The deputy manager was advised that a review should be held without any further delay, to be arranged by the home and inviting the relevant care manager to attend. A requirement applies. Generally, service users indicated that the home is meeting their care needs and that care staff are both caring and supportive. The inspector spoke to a large number of service users including two recently admitted service users. Both expressed their satisfaction with the care and support being provided by staff, and that their care needs have been well met since their admission. This service user has not, as yet, had a formal contract put in place. Standard 2 is clear that a written contract must be provided at the point of moving into the home. This is an outstanding requirement. 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 noted comments from visiting relatives and friends that were generally very positive. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 10 Service users’ 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 service users’ health care needs are being fully met. Service users are being protected by the home’s medication policies and procedures. There has been recent accredited medication training for staff. Service users are being treated with respect and their right to privacy is being maintained. EVIDENCE: The inspector examined a sample of service user’s care plans. These provide considerable detail concerning service users’ identified needs and indicate the Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 14 involvement of service users in developing care plans. There was evidence of care plan reviews taking place with care plans being updated and amended when necessary. Care plans are now 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 number of service users’ care plans and risk assessments, which evidenced that this is generally being done. Two recent admissions (one of whom is currently in hospital) are, however, requiring risk assessments (see standard 4). The inspector and spoke to a wide range of service users regarding their general health and the ability of the home to meet their health care needs. Service user’s care plans and notes were also examined. This indicated a generally high level of satisfaction, with service users indicating that their health needs are being met. Service users’ records, and discussion with the deputy manager, indicate that where health concerns arise, these are being addressed. 10 of the Home’s 17 service users are registered with a local GP practice. The Deputy Manager has advised that the local practice is no longer accepting registrations from the Home and that for all recent admissions the Home has had to refer to the local health trust for a GP to be allocated. As a result, a number of service users are now allocated to two other GP practices. As indicated by the deputy manager, this situation is not ideal but is outside of the home’s control. Where individual concerns arise regarding GP cover the health interests of service users, the deputy manager is encouraging relatives to make representations to the FPC (Family Practitioner Committee). The Deputy Manager advised that one service user receives regular visits from a district nurse, and that other service users receive contact from health professionals as and when required. A chiropodist visits the home and service users are enabled to attend dental, optician and outpatient appointments as and when required. The inspector noted from the accidents and incidents record that two service users had been referred to Accident and Emergency, following a fall, since the last inspection. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 15 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 inspector has been advised that the home has changed to a different pharmacy, due to a deterioration in the quality of service provided by the previous pharmacy. The deputy manager advised that accredited medication training has subsequently been provided by the new pharmacy (on 10/11/05) to all of the home’s staff. This training has now been evidenced with the relevant certification. The inspector spoke to a number of service users regarding their views on whether privacy and dignity is being respected. 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 service users’ doors before entering and to be respectful of individuals’ wishes and needs. The inspector is satisfied that the home has a commitment to maintaining the privacy, dignity and respect of its service users. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 15 Service users are being provided with opportunities for recreational and social activities sufficient to meet their existing needs. Service users expressed their satisfaction with the range of activities provided. Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Service users 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 to them. EVIDENCE: Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 17 The inspector spoke to a wide range of service users. Feedback indicated that services users generally felt very satisfied with the range of activities provided, and that their needs, in this area, were being well met. The home provides a varied programme of activities. This includes weekly visits from musicians or entertainers, reminiscence therapy and bingo sessions. The inspector was able to observe service users enjoying an afternoon live music session from a group of visiting entertainers/musicians (The Melodeons) which seemed popular with the service users, who were encouraged to join in with the singing of some popular songs. The inspector spoke afterwards to the entertainers who indicated that of all the homes they visited, Hollybank was one of the best, providing a homely atmosphere and being encouraging of their efforts to involve service users in their musical sessions. The deputy manager advised that activities include a regular weekly activities session, organised by a visiting group (Total Fitness), which includes activities such as exercises, quizzes, and games. The deputy manager advised that there are occasional outings to the theatre or concert hall; these have included recent outings to the Fairfield Halls, for a Christmas Pantomine and a concert by the London Mozart Players. There are also trips out for tea and shopping trips. There is also a local Residents Association (Kenley Residents Association) which arranges occasional social events and entertainment for service users and staff. Service users are encouraged to maintain contact with relatives and friends. While there is no separate room for receiving visitors, service users are able to receive visitors in their own rooms, or to go out with relatives or friends for tea or a visit somewhere. Service users spoken to by the inspector said that visitors are made welcome by staff when they visit the home. Throughout the inspection it was observed that service users’ personal autonomy and choice is respected, this being included in the home’s Charter of Rights. Service users spoken to by the inspector felt that their individuality was respected and that they had considerable freedom in their daily routines with which to make decisions as to where and how to spend their time, and regarding their choice of clothes and layout of their rooms. Service users 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. Service users are encouraged to manage their own finances wherever possible. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 18 The home has a philosophy of positively trying to enable service users to participate as fully as possible in the daily life of the home, and to achieve the maximum possible independence within their capabilities. One service user who likes to work in the kitchen is allowed to do so subject to a risk assessment being in place. The registered person and staff are very committed to ensuring that service users received good wholesome meals. There is a four weekly rotational menu within the home which provides for a varied, wholesome and nutritious diet. Meals are home cooked and varied to provide choice and meet individual preferences. Service users are offered 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. The inspector observed meals being served in the communal dining room. These can, alternatively be taken in the service user’s own room if he/she wishes. The dining room presents as clean, homely and pleasantly arranged, with the day’s menu being displayed. The main courses are served with fresh vegetables and looked very tasty and appetising. Service users are offered a choice of breakfast, a cooked mid-day meal and a lighter evening meal. Drinks are readily available and snacks can be obtained upon request. The inspector received very positive feedback from service users regarding both the quality and quantity of the meals, one service user saying that she had put on a stone in weight since moving into the home some months previously. The inspector spoke to staff involved in preparing and serving food. A daily alternative to the main course and main dessert is provided, and the dietary needs of one diabetic service user are being met. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are able to raise any concerns they may have. The legal rights of service users within the home are being protected and promoted. Service users are encouraged and assisted to vote if they wish. The home’s policies, procedures and practice are providing service users with protection from abuse. All care staff have now completed statutory adult protection training. EVIDENCE: The home’s complaints policy meets the criteria required by this standard. This is available for service users, 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. The registered provider facilitates monthly residents’ meetings, which assists in identifying any concerns that service users may have. Service users spoken to by the inspector indicated that they feel able to raise any concerns that may arise, and that these are sympathetically and effectively addressed. There have not been any complaints made to the home since the last inspection. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 20 In keeping with a previous recommendation, the home maintains a record of any concerns or compliments. The inspector noted 3 letters, 2 cards and 1 text message that provided evidence of compliments from the relatives and friends of service users. The home aims to fully protect service users’ legal rights by involving family and friends in respect of their contracts, benefits and monies, and in attending reviews. The deputy manager advised that the home does not act as an appointee on behalf of service users, but that where the service user 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 service user has no friends or family. The home maintains records of service users’ expenditure, with monies being reclaimed where appropriate. The inspector examined some records of service users’s expenditure; these were being appropriately maintained. The deputy manager has advised that service users are enabled to participate in the civic process, being encouraged to vote in elections if they so wish. The home has an 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. A requirement, outstanding from the last two inspections, for all staff to receive statutory adult protection training, has now been addressed. The deputy manager advised that, due to the long delay in obtaining places for Croydon’s vulnerable adult training, the home had approached an accredited Croydon trainer to undertake the relevant training with all of the home’s staff. She visited the home, to undertake the training, on 27/2/06. The inspector spoke with a number of service users. Views expressed indicated that service users feel safe and secure within the home, and able to express any concerns that may arise to the manager or deputy manager. No concerns were identified. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 to 26 Service users 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. Service users’ rooms present as being safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Service users have access to safe and comfortable communal facilities. Service users presented as very satisfied with their environment. Sufficient bathing, washing and toilet facilities are currently in place. The home has been assessed as safe to meet the needs of service users, providing sufficient aids and adaptations. Service users live in a home that presents as clean, pleasant and hygienic, and in which staff’s awareness of hygiene issues and practice has been raised through infection control training. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 22 EVIDENCE: The inspector completed an inspection of the premises and spoke to a number of service users, the majority of whom were sitting in the communal areas, but some of whom were in their rooms. There was general satisfaction expressed with the home and the environment and facilities provided. The inspector spoke to two recently admitted service users, one of whom was in her room. Both service users expressed their satisfaction with the communal living areas in the home and with their rooms and the facilities provided. Service users bedrooms were observed to be pleasantly decorated and personalised to reflect individuals’ identities and tastes. Some of the service users bedrooms have had ensuite washing and toilet facilities added following a programme of refurbishment. Including the 3 new bedrooms in the annexe, 7 single bedrooms and the one double bedroom have ensuite facilities. The home has accessible toilets on all floors, with raised toilet seats and grab rails being provided to assist the service users. Washing and bathing facilities were observed to 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 carried out, the inspector viewing records detailing the checks. These were up-to-date and completed appropriately. 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 has been recently installed, this having been risk assessed for all service users who are using this. The deputy manager has been advised that this must be regularly serviced on a sixmonthly basis. 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. One service user (living in the annexe) has stated a preference for not having one. The home was observed to meet good standards of cleanliness and hygiene. In 2005 the home complied with a requirement for an audit by an infection control nurse to be carried out. The report evidenced that satisfactory standards were generally being maintained. All staff at the home have been provided with infection control training (on 8/6/05), and clear guidelines in this area are in place. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 23 Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 to 30 While, generally, service users’ needs are being met, there are, at times, an insufficient number of staff on duty to ensure that there is adequate support available. This presents a potential risk to the welfare and safety of service users and must be rectified. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home is on track for meeting the target of 50 of staff with NVQ Level 2. Service users are generally being safeguarded by satisfactory recruitment policy and procedures, and the necessary recruitment checks. The home is now ensuring that CRB (Criminal Records Bureau) checks are completed prior to commencing the employment of any new staff. Staff are generally being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of service users. EVIDENCE: Staffing levels have previously been maintained as agreed under the previous Care Home Regulations, and as appropriate to the number and assessed needs of the home’s service users. There are currently 17 service users in residence, most of who are physically very frail and who have a range of associated disabilities. The home currently has its full quota of seventeen service users. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 25 The staff levels on the days of inspection were observed to meet the agreed staffing levels. On duty were the registered manager, deputy manager, two care assistants, and an ancillary worker. The home has to recruit a new cook, and care staff are currently having to assist with preparing meals. The inspector examined staff rotas and found that these to be properly maintained and available for inspection. The rotas indicate that while staff levels are now being maintained at the required level of 3 on weekdays, there are still only 2 staff appearing on the Saturday and Sunday afternoon shifts (between 2 and 9 pm). Feedback from a number of service users has indicated that there are not always sufficient staff around to assist, particularly over weekends. The inspector reminds the home that it must fully comply with the outstanding requirement for 3 staff to be on duty at all times throughout the day, both on weekdays and at weekends. Staff rotas evidence that, at nights, there is one waking and one sleep-in staff member who are on call. This is in line with a previous requirement. There have not been any new staff appointments since the last inspection, hence it was not possible to do any staff recruitment checks on this visit. While over the last 12 months, the home has shown an improvement in completing recruitment checks, this needs to be sustained, and will be closely monitored at future inspections. The deputy manager advised the inspector that of 12 care staff, four currently possess an NVQ Level 2, with two others currently registered and due to commence study for this, and one for her NVQ Level 3, from September 2006. The home must aim to meet the 50 target of staff with an NVQ Level 2 within the prescribed time-scale to 31/03/07; a requirement applies. The deputy manager advised that she has completed studies for her NVQ Level 4 and Registered Manager’s Award, and is awaiting her certificates. The inspector spoke to a number of service users. This indicated that service users are satisfied that care staff are sufficiently aware of their needs, and that they show understanding and competence in meeting these. No concerns were expressed. The deputy manager, Deborah Barrett, is delegated responsibility for supervising the staff training programme. A training and development programme is in place. Records are in place for all staff training, and a rolling programme of staff training and refresher courses is available for all staff. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 26 Staff training has included statutory adult protection (27/2/06), accredited medication (4/10/05), health and safety (10/11/04), and food hygiene (3/11/04), health and safety (10/11/05), manual handling training (19/10/04), fire safety (17/3/05), and infection control (8/6/05). 3 staff members have completed emergency first aid, two as part of their NVQ2. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 33, 35 to 38 The registered manager, with the support of the deputy manager, is managing the home in a caring and responsible way. The management of the home needs, however, to demonstrate that it is meeting its aims and objectives and that it is being run in the best interests of service users. Service users’ financial interests are being safeguarded by the home’s policy, procedures and practice. With regular, one-to-one supervision now being provided, service users can generally be assured that staff will be appropriately supported in meeting their needs. However, for sufficient protection to be in place, new staff members should receive more frequent supervision in the early months of their employment, and all staff should be annually appraised. Generally, the interests of service users are being safeguarded by the home’s record keeping, with records being secure, up to date and accurate. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 28 To provide sufficient protection for service users, the home must ensure that all of its policies and procedures are reviewed at least annually. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected; however, for service users and staff to be assured as to their safety, the home has to demonstrate that it is complying with all health and safety, and fire safety requirements. EVIDENCE: From the evidence of this inspection, the inspector was satisfied that the home is being managed in a generally competent way, and that the management style is open and inclusive. The inspector spoke to a wide range of service users. Feedback indicated that service users feel very much ‘at home’ at Hollybank, and that management and staff are perceived to be caring and responsive to their needs. Two recently admitted service users expressed their satisfaction with the home and with the support offered by staff. The home’s registered provider is also the registered home manager; a deputy manager supports her. Following previous concerns regarding communication, the deputy manager has advised that the manager and deputy manager are maintaining a daily communications log; this itemises issues and matters arising during each day. A requirement for regular supervision of the deputy manager by the registered manager has been met. One concern identified related to the absence of any recent staff meetings, the last of which was recorded as being held in January 2006. Staff must be evidenced to be fully consulted and involved in the day-to-day running of the home, with regular monthly staff meetings taking place. A requirement applies. A requirement from the previous inspection remains to be fully met. The home has been developing its quality assurance processes. The deputy manager advised that questionnaires have been compiled and completed with service users, relatives/friends, professionals, care managers and others visiting the home. The home has yet, however, to put in place a development plan. The inspector was informed that this is in preparation and is due to be completed. This should aim to detail the feedback received from questionnaires and other sources, provide an evaluation of the home’s ability to meet its stated aims and objectives, and identify priorities for addressing any shortcomings and plans for the year ahead. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 29 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. The inspector spoke to a large number of service users, no concerns being expressed in this regard. The deputy manager advised that 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. These records were inspected and found to be satisfactory. 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. Following a concern identified at the previous inspection, the registered manager must ensure 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. This was not possible to verify as no new staff have taken up post since this concern was identified. The home’s registered manager and deputy manager are currently undertaking supervision. Some delegation of the supervisory workload within the home is being considered. To facilitate this, a senior care worker should be provided with a job description that includes staff supervisory and appraisal responsibilities; relevant training should also be provided. A recommendation applies. Generally, the interests of service users were found to be be safeguarded by the home’s record keeping, with records being secure, up to date and accurate. 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 upkeep of records, these being maintained in reasonably good order. The inspector recommends, however, that new files for service users are 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 would provide a more structured and orderly storage of information. However, the home must ensure that all of its policies and procedures are reviewed at least annually. The deputy manager advised that she is currently Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 30 undertaking this task and expects to complete this within the next few weeks. A requirement applies. The inspector completed an inspection of the premises and requested documentation regarding health and safety, and fire safety checks. Generally, the health, safety and welfare of service users and staff were evidenced to be appropriately promoted and protected; the premises presented as generally well-maintained and no specific concerns were identified. Health and safety risk assessments for the home were last completed on 22/7/04 and are currently being updated. There were, however, a number of servicing, maintenance and safety monitoring checks, which had not been recently completed. These included servicing of the gas boiler and supply (last serviced on 22/3/05), legionella inspection for the home’s water storage (last completed in November, 2004), and weekly fridge and freezer checks (not evidenced since the end of December 2005). There was also a recent lapse in maintaining weekly fire break-glass point tests (last recorded as completed on 24/2/06). The home’s Fire Risk Assessment which the inspector was informed was last completed at the end of November 2005, was unsigned and undated. Requirements apply. All other health and safety checks made were found to be satisfactory; the 3 yearly electricity installation inspection is due next month, having last been completed on 19/5/03. Portable electrical appliances were last inspected on 16/8/05. The home’s manual hoist and bath hoist are being serviced 6 monthly (last done on 9/3/06). The home has recently had a stair lift installed which the inspector understands has met planning and health and safety requirements. All service users who use this have been risk assessed. The deputy manager was, however, reminded of the need to ensure that the stair lift is regularly serviced at six monthly intervals, and was advised to check this out with the supplier. The home has received its annual fire inspection by the LFEPA (London Fire and Emergency Planning Association) on 16/9/05, with all recommendations having been subsequently addressed. Fire extinguishers were last serviced on 5/7/05. Fire alarms, emergency lights and the nurse call system were evidenced to have been serviced on a regular 3 monthly basis. Fire drills are taking place 3 monthly and staff have received fire safety training. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 31 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 2 2 3 3 X 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 2 3 2 Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 32 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 OP2 Regulation 5(b & c), Sch4, No8 Requirement The registered manager must ensure that a written contract is issued to a service user who was admitted on 17/11/05. Previous timescale not met. The registered manager must ensure that care reviews are held for all service users, following their admission to the home. This includes a service user, admitted on 17/11/05, who must be reviewed without any further delay. The care manager must be invited to attend for all service users referred by social services. Previous timescale not met. Risk assessments must be completed for two recent admissions. The registered manager must ensure that there are 3 staff on duty at all times throughout the day, both on weekdays and at weekends. Partly, but not fully met. Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 33 Timescale for action 31/05/06 2 OP3 14(2a) 31/05/06 3 OP7 12(1)(a) 13(4)© 18(1)(a) 31/05/06 4 OP27 30/04/06 5 6 7 OP30 OP32 OP33 18(1)(a) & (c) 21(1) & (2) 24(1-3) 50 of the home’s care staff 31/12/06 must be qualified to NVQ Level 2. Staff meetings must be held on a 31/05/06 regular monthly basis. The registered manager must ensure that a development plan for the home is put in place. Previous time-scale not met. The registered manager must ensure that annual staff appraisals are carried out. Previous time-scale not met. The registered provider must ensure that all of the home’s policies and procedures are reviewed at least annually. 31/05/06 8 OP36 18(1a&2) 31/05/06 9 OP36 12(1)(a) 30/06/06 10 11 12 13 14 OP38 OP38 OP38 OP38 OP38 23(4)(a) 23(4)(a) & (c)(v) 13(4)(a) & (c) 13(4)(a) & (c) 13(4)(a) & (c) The home’s Fire Risk Assessment 30/04/06 must be signed and dated. Fire break-glass tests must be completed on a weekly basis. Servicing of the gas boiler and supply must be completed annually. Legionella inspection and testing must be completed annually. Fridge/freezer checks must be evidenced on a weekly basis. 30/04/06 31/05/06 30/06/06 30/04/06 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 a member of staff who is being considered for supervisory responsibilities is enrolled DS0000025794.V291829.R01.S.doc Version 5.1 Page 34 Hollybank for training leading to NVQ Level 3. This will assist in furthering her professional development. 2 OP36 The inspector recommends that that there is some delegation of the supervisory workload within the home. To facilitate this, a senior care worker should be appointed with a job description that includes staff supervisory and appraisal responsibilities; relevant training should also be provided. Service users’ files should include a copy of all the documentation detailed in Schedule 3(1), (2) and (3). The inspector recommends that new files for service users are developed, with a front index, and separate sections for service user information, assessments, care plans, health, medication, record of accidents/incidents, activity charts, and daily care notes. 3 OP37 Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 35 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hollybank DS0000025794.V291829.R01.S.doc Version 5.1 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!