Inspection on 29/07/05 for Hollybank

This inspection was carried out on 29th July 2005.

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

The inspector 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 21/06/07

Hollybank 07/11/06

Hollybank 24/01/06

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 Paul Kenyon Unannounced 29th July 2005 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 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 F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hollybank Address 27 Park Road Southport Merseyside PR9 9JL 01704 530748 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Ann Mallinson Mrs Ann Mallinson Care Home 16 Category(ies) of OP - Old Age registration, with number TI - Terminally Ill of places Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 16 OP and up to 2 TI Date of last inspection 3rd March 2005 Brief Description of the Service: Hollybank is a privately owned Care Home providing nursing care for 16 older Service users. The Registered Provider and Registered Manager is Mrs Ann Mallinson. Hollybank cares for 16 Services and accommodation comprises of 10 single bedrooms with 1ensuite and 3 double bedrooms with 1 en suite. On the day of the inspection there were 15 service users resident. The home is registered to take 2 service users with palliative care needs although no service users have received this specialist care of late.Hollybank is situated in a quiet residential area of Southport close to the town centre, local amenities, the beach, Hesketh Park and access to local public transport. 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 wheelchair access. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours. During the inspection fifteen residents were living within the home. The initial part of the inspection included discussions with residents. In total five residents offered their views and a relative of one resident also gave an account of the care their relation received. The rest of the inspection included a tour of the premises and examination of records, policies and procedures. What the service does well: What has improved since the last inspection? Hollybank now has a clearer process for the assessment of individuals prior to them coming to live at the home. In addition to this a fire risk assessment has now been devised. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Standard 6 is not applicable to the home at present. Assessments are clear, indicate the needs of service users and are undertaken and obtained before they receive care at Hollybank. EVIDENCE: Two assessments relating to individuals who had been admitted since the last inspection were viewed. One related to a person who was privately funded. In this case, the home had conducted its own assessments and the needs of this person were identified and were transferred over to their plan of care. A Local Authority was funding the other individual. In this case, an assessment had been provided by a social worker and in addition to this, the home had conducted its own assessment. The assessments indicated that the needs of the individuals could be met by Hollybank and placed an emphasis on the nursing needs of both people as well as their social needs. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9 Care plans indicate the needs of individuals and are reviewed. The signing of care plans by the individual or their representatives is inconsistent. Medication systems are safe and demonstrate accountability. The health needs of individuals are met. EVIDENCE: A number of care plans were examined. In all cases, the plans are reviewed on a monthly basis. The content of care plans indicate not just the nursing and physical needs of individuals but also indicated their social needs. All care plans with the exception of one had been signed by the individuals’ representative. The care plans include details of the health needs of individuals as well as lists of appointments that had been attended. Such medical interventions included visit to GPs, chiropodists, dentists and opticians. One service user confirmed that she had recently received new digital hearing aids and thought that they were ‘much better’. Another service user considered that her health had improved while she had been in Hollybank and particularly her mobility. All service users are registered with a General Practitioner. All care plans included assessments of the individuals susceptibility or otherwise to pressure sores. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 10 Only one person has a pressure sore at present having been recently admitted from hospital. All pressure sore assessments are reviewed on a regular basis. Other considerations are made to the psychological health of service users were applicable with referrals made to Community Psychiatric Nurses. Records also suggested that nursing staff in the home make regular observations in relation to blood pressure and pulse rates. The mobility of individuals is taken into account with activities including light exercise sessions. The continence needs of individuals are also assessed. Medication is stored in a lockable trolley, which is secured to a wall when not in use. No service user self-administers their medication at present. Controlled medication is prescribed for three people. This is stored separately in a secure medication cabinet and a controlled medication register is maintained. All medication administration records are appropriately signed. Registered Nurses are responsible for administering medication and evidence was available suggesting that they received training updates from the pharmacy supplier. A copy of a British National Formulary (which details types of prescribed medications and potential side effects) is available to nursing staff. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12 Routines of daily living are flexible and activities are available to those who wish to participate. EVIDENCE: All service users who offered their views during the inspection confirmed that activities take place. Some confirmed that while activities were on offer they did not want to join in yet felt that this preference was respected. All who offered their views confirmed that while mealtimes are set, they felt that this was needed given that the staff had to cater for so many people. All confirmed that they are able to get up in the morning and go to bed when they wished although some preferred to retire earlier in the evening. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16 and 18 A clear complaints procedure is available to service users. Service users are protected from abuse in the main through the availability of policies and procedures and the recruitment process. The home must provide its Local Authority procedure for inspection and for reference. EVIDENCE: A complaints record is available although no complaints have been made. The Commission For Social Care Inspection has received no complaints. Many service users stated that they ‘had no complaints’. They suggested that if they did they felt ‘confident that the Manager would deal with them’. The home has its own ‘guarding against abuse’ policy. No copy of the Local Authority procedure for the reporting of allegations of abuse was available and this is raised as a requirement in this report. In addition to this, the home has policies in relation to staff expressing concerns through a ‘whistle blowing’ procedure. Information on staff’s involvement in receiving gifts and being involved in the making of wills is available and prohibits staff from being involved. Information is also available in respect of restraint and dealing with physical of verbal aggression. Most staff have signed these policies with the exception of one person. It is recommended that this person identified at the inspection sins these policies. The recruitment process includes checks against the protection of vulnerable adults register. Many service users stated that they ‘feel safe’ living at Hollybank. A relative present during the inspection reiterated this view. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 13 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 standard(s) No standards relating to this section were measured during this inspection. EVIDENCE: Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The recruitment procedure is robust and protects service users. EVIDENCE: Only one person has started employment in the home since the last inspection. Proof of identity was in place as well as two references. In addition to this a police clearance check had been carried out with reference to the protection of vulnerable adults register. The registration numbers for registered nurses were examined and initially one could not be located. This was addressed subsequent to the inspection. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,38 Health and safety of individuals in the home is maintained. EVIDENCE: A certificate of insurance was available for inspection but this had expired. Evidence of current insurance was provided subsequent to the inspection. Health and safety systems checked on this inspection included mandatory training for staff. All this training had been received. The cook is about to go on an intermediate food hygiene course. Fire systems are in place and this included fire extinguishers checked each year and regular fire alarm tests and testing to emergency lighting systems. A fire risk assessment is now in place. All fire exits were clear during the visit. Accidents are recorded and it was noted that four accidents had occurred since the last inspection. Water temperatures are recorded prior to service users being bathed and thermostatic valves are installed on some hand washbasins. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 16 The passenger lift has been serviced as well as portable and fixed hoists in the building. The electrical wiring of the home has been certified as safe and the gas systems are to shortly be assessed. Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x 3 x x x 3 Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 18 NO Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 Requirement Care plans must be signed by service users and/or their representaive to confirm agreement with the plan The Local Authority procedure relating to the referral of allegations of abuse must be available for staff reference Timescale for action 31 August 2005 31 August 2005 2. 18 13 3. 4. 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 18 Good Practice Recommendations The member of staff identified during the inspection should sign the guarding against abuse procedure Hollybank F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Burlington House South Wing 2nd Floor Crosby Road North Waterloo, Liverpool L22 0LG 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 F53 F03 S17242 Hollybank V241887 29.07.05 Stage 4.doc Version 1.40 Page 20 - 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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