Inspection on 29/09/05 for Hollybank

This inspection was carried out on 29th September 2005.

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

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

Other inspections for this house

Hollybank 20/04/07

Hollybank 27/04/06

Hollybank 24/01/06

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 Unannounced Inspection 29 September 2005 9:30am 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 G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hollybank Address 5 Abbots Lane, Kenley, Surrey, CR8 5JB 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) 020 8660 4213 Mrs Valerie Taylor Mrs Valerie Taylor Care Home 17 Category(ies) of Old Age (17) registration, with number of places Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 24 September 2004 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 G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 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 and to staff on duty. Care records and other documentation were examined. As a result of this inspection ten requirements have been made, three of which are unmet from the previous inspection. The inspector was concerned by the failure of the home to have obtained care management assessments and a care plan from social services prior to the admission of three recently admitted service users. Whilst the home have completed their own assessments, there is a responsibility under the Care Home Regulations for the home’s management to ensure that no decision regarding admission is made until the relevant care management assessments and care plan have been supplied. The failure to have obtained full information concerning the person’s assessed health and care needs places the service users and staff responsible for their care at potential risk. A statutory care review, to assess the suitability of the placement in meeting the needs of two of these service users (admitted in April and May 2005), has not yet been held; this is a further cause for concern, and one that must be addressed as a priority. Another area of concern is that care staff are not, as yet, being provided with regular, one-to-one supervision. This is potentially compromising the safety and welfare of service users. The inspector has advised the home that this will become an enforcement issue if this requirement is not fully met. The home has had a recent fire inspection from the LPEFA (London Fire Emergency Planning Authority) as a result of which the home has to address a number of fire safety concerns. A follow-up inspection by the LPEFA to ensure compliance with the actions required of the home is scheduled for 31 October 2005. A requirement from the CSCI also applies. Notwithstanding the concerns identified, the inspector’s overall impression is that Hollybank is a pleasant and generally well-run home, which provides a caring and homely environment for the home’s residents. Feedback from service users, including two who have been recently admitted, was generally very positive. Service users spoken to at the home commented favourably about the care and support they receive, and the caring attitude of the Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 6 management and staff. Care staff on duty at the time of the inspection were observed to be interacting with the service users in a caring, respectful and professional manner. The inspector would like to extend his thanks to the home’s manager and deputy manager for their assistance throughout the inspection, and to both service users and staff for their involvement. What the service does well: The home is providing a generally good standard of care for the service users, and involving them in drawing up their care plans. The home is ensuring that service users’ health care needs are being monitored and met. Service users are being treated with respect and their right to privacy is being maintained. Service users are being provided with varied 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. The home is welcoming to visitors. 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. A risk assessment of the home is in place for their protection. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 7 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 the 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. 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. What has improved since the last inspection? A revised risk assessment format has been put in place. This clearly identifies areas of risk and the actions agreed with the service user for managing these. Risk assessments and care plans are now evidencing the agreement of the service user and/or his representative. The home is now on track for meeting the minimum 50 requirement for care staff to achieve an NVQ Level 2 qualification by 2005. Following a requirement from the previous inspection, CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks for new staff are now being obtained prior to the commencement of their employment at the home. This is essential in helping to protect service users from possible abuse and must be maintained. Service users are generally being safeguarded by satisfactory recruitment policy and procedures, and the necessary recruitment checks. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 8 An infection control nurse has completed an audit of the home and all staff have undertaken infection control training. Following a requirement from the previous inspection, all staff have now completed training in manual handling. Following a requirement from the previous inspection, regular two-monthly fire drills for service users and staff are now being undertaken. Service users’ financial interests are being safeguarded by the home’s policy, procedures and practice. A concern relating to the safekeeping of a service user’s valuables, from the last inspection, has been satisfactorily addressed. What they could do better: Whilst the home has undertaken its own assessments, it has failed to ensure that care management assessments and care plans, relating to the care needs of recently admitted service users, have been obtained prior to admission. While service users are generally having their care needs reviewed, two service users (admitted in April and May 2005) have not, as yet, had an initial statutory care review to assess the suitability of the placement in meeting their needs. These must be arranged within the required time-frame of 6 to 8 weeks following admission. While service users have care plans in place, detailing their health, personal and social care needs, and how these are being met, the care plans are not currently being reviewed on a monthly basis. These must be reviewed monthly forthwith. Following a requirement from the previous two inspections formal one-to-one supervision of care staff is now being undertaken. This is not, however, taking place on a sufficiently regular basis. For service users to be assured that staff will be appropriately supported in meeting their needs, regular, one-to-one supervision must be provided, together with an annual appraisal. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 9 While, generally, the home’s policies, procedures and practice evidence that service users are being protected from abuse, their protection also requires that adult protection training is extended to those care staff who have not so far undertaken this. The management of the home needs to demonstrate that it is meeting its aims and objectives and that it is being run in the best interests of service users; a Development Plan is required. The health, safety and welfare of service users and staff are generally being appropriately promoted and protected; the home has, however, to demonstrate that it is complying with fire safety regulations and address a number of fire safety concerns identified in a recent fire safety inspection. In order to demonstrate the home’s financial viability, a copy of the annual, audited accounts for the year ending 2004 must be provided. 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 G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 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 standard(s) 2 to 5 Whilst, generally, service users are being provided with clarification of the terms and conditions of their placement, with a written contract, one service user admitted in May 2005 has yet to receive one. Whilst the home has undertaken its own assessments, it has failed to ensure that care management assessments and care plans, relating to the care needs of recently admitted service users, have been obtained prior to admission. In the absence of full information concerning health and care needs, both service users and care staff are being placed at potential risk. While service users are generally having their care needs reviewed, two service users (admitted in April and May 2005) have not, as yet, had an initial statutory care review to assess the suitability of the placement in meeting their needs. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. EVIDENCE: Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 12 Standard 1 not assessed. Met at the last inspection. New service users are admitted on the basis of a full assessment being undertaken by a person trained to do so. Records are maintained of both preadmission and ongoing assessments, and a review process that monitors service users’ needs. All assessments examined evidenced the involvement of the service user. The inspector examined a number of service user files which included the home’s own assessment format. These were observed to be detailed and comprehensive with all service users having been assessed by a member of the home’s management. 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. While the home had completed its own assessments, risk assessments and care plans, three of the four service users did not have care management assessments and care plans in place; these must be provided whenever the service user has been referred by health or social services. The deputy manager was advised that these must be received prior to a decision being made regarding admission, and that all referrals from these agencies must include this documentation. A requirement applies. Two of these service users, admitted in April and May 2005, have not, as yet, had a six-weekly statutory care reviewfollowing their admission. This is essential in enabling discussion with the service user and his relatives/representatives as to whether the placement is suitable in meeting his/her needs. Reviews, involving the respective care managers, must be arranged without any further delay. A requirement applies. The home has it’s own in house contract/purchasing of care agreement, which is agreed with each service user. These documents are signed and in line with the requirements of the Regulations and standards. The contracts are clear and well laid out to ensure that the service user and his/her representatives understand the information and conditions of admission to the home. The Local Authority renewed all contracts in April 2004 following the notification of fees increases. One service user, admitted in May 2005, has still not, however, 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. A requirement applies. The inspector spoke to a number of service users during the course of the inspection. Service users indicated that the home is meeting their care needs and that care staff are both caring and supportive. Two service users, one with visual impairment, who have been recently admitted to the home, both spoke highly of the home and of the care that they are receiving. 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 Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 13 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 home does not provide intermediate care. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 14 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 While service users (and their relatives/representatives) are being involved in the process of drawing up their care plans, detailing their health, personal and social care needs, and how these are being met, the care plans are not currently 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. EVIDENCE: Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 15 Service user care plans provide considerable detail concerning identified needs and indicate the 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. In line with Standard 7.4, these should, however, be reviewed on a monthly basis; a requirement applies. Risk assessments are being carried out by the home as part of the Home’s assessment. There was an outstanding requirement from the last inspection for risk assessments and care plans to evidence the agreement of the service user and/or his representative. The inspector examined a number of service users’ care plans and risk assessments, and evidenced that this is being done. A requirement for a risk assessment format has also been met. The new format clearly delineates areas of risk and the actions agreed with the service user in managing these. The inspector examined service user’s care plans and notes, and spoke to a number of service users concerning their health care needs. This indicated that the home is monitoring individuals’ health and well being, providing appropriate care, and addressing health concerns when these arise. 13 of the Home’s 17 service users are registered with a local GP practice. The Deputy Manager advised that the local practice is no longer accepting registrations from the Home and that for the last four admissions the Home has had to refer to the local health trust for a GP to be allocated. 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. The home has a Charter of Rights in place which outlines its obligations in respect of residents rights in regard to personal choice, privacy and decisionmaking, their right to being treated with dignity and respect, and rights in regard to undertaking activities/ risk assessment, and in maintaining a level of independence. A copy of the charter is provided to each service user. The inspector spoke to a number of service users, with positive views being expressed regarding the caring attitudes of the home’s management and care staff, with residents feeling that their rights and privacy are being 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 Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 16 commitment to maintaining the privacy, dignity and respect of its service users. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 17 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, 13, 14 and 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: The inspector spoke to a number of service users who felt that the home provided 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 Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 18 session from a visiting keyboard and guitar duo (Simon and Beth), with encouragement to join in with the singing of some popular songs. 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 which include trips out for tea, to the theatre or concert hall, and shopping trips. Three service users recently went on a day trip to Brighton. A forthcoming attraction is a Fish and Chips Supper organised by the local residents association and a pantomime visit is due again at Christmas. The home also has its own Residents Association called ‘Touche’ 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. 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 Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 19 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. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 20 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, 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. While, generally, the home’s policies, procedures and practice provide evidence that service users are being protected from abuse, their protection also requires that adult protection training is extended to those care staff who have not so far undertaken this. 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 which 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 G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 21 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 saw the records of a service user’s expenditure which 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. Service users indicated to the inspector that they feel safe in the home and that staff are caring and sensitive to their needs. 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. ‘ Following an outstanding requirement from the last inspection 7 of the 11 care staff have attended Croydon’s Multi-Agency Vulnerable Adult and Adult Protection training; the registered manager and 4 care staff have still to attend this training, hence the requirement remains to be fully met. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 22 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) 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. EVIDENCE: Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 23 The premises were inspected and found to be accessible, and well-maintained. All communal areas are well furnished and equipped providing comfort and privacy and meeting the assessed needs of the service users. The lounge has a pleasant homely feel. An outdoor verandah area, overlooking the wooded garden, has been extended outwards from the main lounge. This provides an attractive place for service users to sit and relax. The dining room has been redecorated and provides a pleasant environment for taking meals. Service users expressed their satisfaction with their bedrooms. These are generally in a good decorative state, several of these having been redecorated or refurbished, and reflecting the personal tastes of their occupants. Rooms are personalised to reflect individuals’ identities and tastes. Following a requirement from the previous inspection the floor covering in a service user’s room has been replaced. 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 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. 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 back fire entrance were installed. Heating, lighting and ventilation throughout the home present as satisfactory. Lighting is domestic in character and in keeping with the homely atmosphere. One service user’s room in the annexe area was observed to lack a bedside lamp; the inspector is making a requirement for the service user to be consulted as to the person’s wishes in this regard, and for a bedside lamp to be provided if this is required. The home was observed to meet good standards of cleanliness and hygiene. Since the last inspection the home has complied with a requirement for an audit by an infection control nurse to be carried out. The report was viewed by the inspector, this evidencing that satisfactory standards are generally being Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 24 maintained. A recommendation for the provision of alcoholic gel for staff to clean their hands in the laundry area has been acted upon, as there is no room for a hand washing facility in this area. 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 G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 25 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) 27 to 30 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 by 2005. 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. All staff have now completed training in manual handling. EVIDENCE: Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 26 The home currently has its full quota of seventeen service users. 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’s cook was not on duty on the day of inspection and other staff were having to assist in preparing food. This was, it seems, an unforeseen eventuality, but one which resulted in a the stretching of staff resources on the day. The inspector examined staff rotas for the week in hand and evidenced that this now includes both one waking staff member and one sleep-in who is on call; thus meeting a requirement from the last inspection. The name of the on-call senior staff member in charge is included on the rota, as required. The deputy manager is on-call herself from Monday to Friday. Following a further requirement from the previous inspection, the inspector examined staff rotas and found that these to be properly maintained and available for inspection. The deputy manager advised the inspector that of 11 care staff, five now possess NVQ Level 2, with three others currently registered and studying for this. The home is, therefore, on track for meeting the 50 target (with NVQ Level 2) by 2005. The deputy manager advised that she has completed her NVQ Level 4 and is currently studying for the Registered Manager’s Award. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 27 The inspector was advised that one new staff member has commenced employment since the last inspection. Checks on staff files evidenced that updated CRB and POVA checks are now being obtained, with the home awaiting the receipt of CRB and POVA checks for two prospective employees. All recruitment and identity checks had been satisfactorily completed for the new staff member. The inspector has been previously concerned by the failure of the home to have CRB checks in place prior to new appointments being confirmed, and will be rigorously monitoring this on future inspections. Service users spoken to by the inspector indicated that they had confidence in the care staff being able to meet their needs. The deputy manager, Deborah Barrett, is delegated responsibility for overseeing the staff training programme. Records are in place for all staff training, and a rolling programme of staff training and refresher courses is available for all staff. Staff training in recent months has included health and hygiene, and food hygiene (3/11/05), health and safety (10/11/05), fire safety (17/3/05), and infection control (8/6/05), The home has also met a requirement for manual handling training for all care staff (19/10/05) following a concern raised at the previous inspection. This is evidenced with certificates from the approved trainer. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 28 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) 31, 32, 33, 34, 35, 36 and 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. A concern relating to the safekeeping of a service user’s valuables, from the last inspection, has been satisfactorily addressed. For service users to be assured that staff will be appropriately supported in meeting their needs, regular, one-to-one supervision must be provided, together with an annual appraisal. The health, safety and welfare of service users and staff are generally being appropriately promoted and protected; the home has, however, to demonstrate that it is complying with fire safety regulations and address a number of fire safety concerns identified in a recent fire safety inspection. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 29 EVIDENCE: The home’s registered provider is also the registered home manager who is supported by a deputy manager. The inspector was concerned at the last inspection that the registered manager and provider had been unable to locate records and had difficulty in responding to some questions relating to issues concerning the management of the home. The deputy manager advised that the manager and deputy manager are maintaining a daily communications log, itemising issues and matters arising during each day. Whilst this is assisting in improving communication, the inspector was concerned to learn that a requirement for supervision of the deputy manager by the registered manager has not, as yet, been met. An extension to the time-scale for meeting this was agreed. Feedback from service users regarding the management of the home was very positive, with several users saying that they feel very much ‘at home’ at Hollybank, and viewing the home as being run in a very personal and caring way. Staff members spoken to indicated that they felt supported in their roles and presented as responsive in meeting service users needs. The inspector observed service users being treated with respect by staff, and being enabled to participate in daily routines and activities. Service users attend residents’ meetings on a monthly basis. These are attended by the manager and deputy manager and provide an opportunity for service users to raise any issues. The inspector noted from the minutes that meetings are being held on a regular monthly basis, with evidence of issues pertinent to the maintenance and running of the home being aired and discussed. There are also regular monthly staff meetings. 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 and others visiting the home. The home has yet, however, to put in place a development plan. 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. The home has provided annual, audited accounts for the year ending 2003. A requirement for a copy of the annual, audited accounts for the year ending 2004 remains to be met. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 30 Service users’ financial interests are being safeguarded with records being kept of any expenditures on their behalf. If relatives provide petty cash for purchases for such items as newspaper, hairdressing and toiletries of their choice records and receipts are kept and shown to the delegated relative as and when necessary. Wherever possible, service users are encouraged to manage their own monies but where this is not possible, relatives or external agencies such as Social services or independent advocacy are invited to act on behalf of service users. A requirement from the last inspection, regarding the safekeeping of service users’ valuables, has been met. The deputy manager advised that any valuables entrusted for safekeeping are now being 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 noted that supervision records are now being appropriately maintained. He was, however, very concerned to find that an outstanding requirement from the last two inspections, for all care staff to receive formal supervision at least six times a year, has not yet been fully met. While formal, recorded one-to-one supervision sessions have taken place, the last recorded supervision sessions took place in March and April 2005, some 5-6 months ago. The deputy manager was reminded that supervision must be held at least two monthly with all staff members, and that failure to comply with this requirement is likely to result in enforcement action being taken. Supervision must include all care staff employed at the home, including the Deputy Manager (see standard 31). Staff appraisals must also be evidenced by the time of the next inspection. The health and safety of service users and staff is being safeguarded by the home’s procedures and practice. The basement area was refurbished in 2004, the laundry area and boiler room having been upgraded to meet health and safety requirements. Window restrictors are in place for security and safety reasons. The inspector completed health and safety checks on the maintenance of the home’s equipment including the servicing of gas, electricity, water supply (legionella), the bath hoist and fire equipment- all were up-to-date. Two concerns from the previous inspection have been addressed. The COSSH cupboard containing cleaning fluids was properly secured, and regular twomonthly fire drills are now being held and recorded. The home has had a fire safety inspection and fire training for staff (on 17/3/05). The deputy manager advised that the home has recently had a fire inspection. As a result of the inspection by the LFEPA (London Fire Emergency Planning Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 31 Authority), a number of conditions (specified in the Fire Precautions (Workplace) Regulations 1997) were found to be contravened, and the actions required to address these are required by the LPEFA to be met by 31/10/05, at which time a further LFEPA inspection is to be made. The CSCI is making it a requirement that all the actions detailed in the LFEPA inspection report are fully met by this date. The steps required to be taken by the home are: 1. To carry out a Fire Risk assessment, record this, and inform all staff of the contents. 2. To remove all combustible materials kept in the boiler room. 3. To enclose the freezer room with 30 minute fire resistant protection, and install suitable fire detection and link to premises fire alarm. 4. To fit a 30 minute self-closing fire door to the boiler room. 5. To adjust all fire doors so that these self close fully. 6. To fit sealed fire resisting glass to the inside of the windows in the ground floor extension corridor. Another concern has been addressed, with fresh vegetables now being stored in a cool, compartmentalised storage rack away from exposed kitchen surfaces and the surrounding area. Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 32 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 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 3 2 3 3 1 x 2 Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 33 Yes 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 OP3 Regulation 14(1)(a,b, c & d) Requirement The registered manager must ensure that care management assessments and care plans are obtained prior to any decision being made regarding admission to the home. The registered manager must ensure that statutory care reviews are held for all service users, following their admission to the home. For two service users admitted on 16/9/04 and 2/5/05, these reviews must be arranged without any further delay, and a copy of the review notes forwarded to the CSCI, Croydon office. The registered manager must ensure that a written contract is issued to a service user who was admitted on 2/5/05. The registered manager must ensure that care plans for all service users are reviewed and updated, as necessary, on a monthly basis. The registered manager must ensure that both she and those care staff at the home who have not yet attended Croydon’s Multi-Agency Vulnerable Adult Timescale for action 1 November 2005 2. OP3 14(2)(a) 1 November 2005 3. OP2 5(b & c), Schedule 4, No.8 15(2)(b,c & d) 1 November 2005 1 November 2005 Time-scale extended to 1 January 2006 Page 34 4. OP7 5. OP18 12 (1)(a) & (b), 13 (6) Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 6. OP24 16(1) & (2) 7. OP33 24(1), (2) & (3) 18 (2) and Adult Protection training, do so without any further delay. The registered manager must ensure that a service user in Room 7 (in the annexe) is consulted as to his wishes regarding the provision of a bedside lamp, and for this to be provided if required. The registered manager must ensure that a development plan for the home is put in place. All care staff must receive formal, recorded supervision at least six times a year. 1 November 2006 8. OP36 9. 10. OP36 OP38 18(1)(a) & (2) 13(4),23 (4) The registered manager must ensure that annual staff appraisals are carried out. All the actions detailed in the 1 LFEPA fire inspection report must November be fully met by 31.10.05. It 2005 must be evidenced that the home has complied with all the LFEPA recommendations by this date. Time-scale extended to 1 April 2006 Time-scale expired. From receipt of report. 1 April 2006 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 Good Practice Recommendations Hollybank G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 Page 35 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon Surrey 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 G53 S25794 Hollybank V195467 290905 stage4.doc Version 1.40 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. 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