Inspection on 14/02/06 for Hollybank House

This inspection was carried out on 14th February 2006.

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

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

Other inspections for this house

Hollybank House 19/02/09

Hollybank House 28/02/07

Hollybank House 20/07/06

Hollybank House 20/09/05

Hollybank House 30/03/05

Hollybank House 20/09/04

Hollybank House 30/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Hollybank House Chesterfield Road Oakerthorpe Derby DE55 7LP Lead Inspector Susan Richards Unannounced Inspection 13th February 2006 10:00 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 House DS0000002172.V275244.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 House DS0000002172.V275244.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hollybank House Address Chesterfield Road Oakerthorpe Derby DE55 7LP 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) 01773 831791 Miss Margaret Ann Bradley Alison Jane North Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 4 places for PD over 50 years which are included within the PCN registration 20 places for PCN - Not to exceed Date of last inspection 20th September 2005 Brief Description of the Service: Hollybank House provides personal and nursing care for up to 40 older persons and including up to 4 service users with physical disabilities aged over 50 years. The original house, formerly a private dwelling, was converted and extended for the purposes of registering as a care home. Accommodation is organised over two floors, with access to the first floor via stairs and a shaft lift. There is choice of communal lounge and dining space to the ground floor and adequate numbers of bathrooms and toilets with adaptations to assist those service users with mobility problems. There is level access to well maintained expansive gardens, with seating provided. There are 24 single bedrooms and 9 double, including 3 single and 2 double rooms, which have en suites. The Manager has the support of a team of Registered Nurses, care and hotel services staff and the registered provider has a high profile within the home. An activities person is also employed, who organises a variety of activities for service users, both in and outside the home, which are both individual and group based. Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was on the management and administration systems of the home, the arrangements for social care and activities for service users and assessment of compliance with requirements and recommendations made at the previous inspection for this service (September 2005). What the service does well: What has improved since the last inspection? A standardised format for recording consultation with service users about their own care plans has been introduced. The registered persons have ensured that all new staff starters undertake the appropriate vetting checks prior to their employment in the home. Seventy two percent of care staff had achieved NVQ level 2. Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 House DS0000002172.V275244.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 the following standard(s): 1&2 Relevant and updated information was provided for residents and their representatives about the home and its services. Each service users had a written contract/statement of terms and conditions with the home. EVIDENCE: The statement of purpose for the home, which details all aspects of the services provided and the service user guide, which summarises this information for residents, had both been updated to reflect changes and updates in respect of staff employed and their training. At the previous inspection for this service a standardised written format of key terms and conditions for service users with the home had been prepared. Individual terms and conditions had since been agreed and provided for all service users (or their representatives). Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 the following standard(s): The standards in this section were not fully assessed on this occasion. A requirement made at the previous inspection for this service in relation to the medicines policy guidance for staff had not been complied with. EVIDENCE: At the previous inspection for this service the arrangements for the management and administration of medicines were examined. These were satisfactory, with one exception in relation to a specified deficit of policy guidance. This had still not been addressed. Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 Page 10 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, 13, 14 & 15 There are satisfactory arrangements to enable residents to participate in activities of their choice and to maintain contact with their families and friends and the local and extended community. Residents are provided with a balanced and nutritious diet and are properly assisted in eating and drinking in accordance with their assessed needs EVIDENCE: On the day of the inspection, the Inspector arrived at the home, unannounced at mid morning. An outside organisation were providing a gentle exercise activities session with some residents. Teas and coffees were being served. One service user was going out, some were chatting with friends and visitors and small group were watching TV. Discussions were held with some service users and staff about the arrangements for activities in the home. An activities co-ordinator is employed who organises a range of activities for residents both within and outside the home, which were in accordance with their lifestyle preferences, choices and abilities. Examples include, board games, outings (both one to one and Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 Page 11 group), beauty sessions and hand massage, weekly trips to the pub for lunch, walks out, regular in house entertainment and seasonal celebrations, including the summer strawberry fete. Residents had particularly enjoyed a dog show, which had been organised with the assistance of the Kennel Club and a group of residents had planned a holiday to Blackpool in May. Records were kept within individual residents care files in relation to activities organised in accordance with residents’ preferences and their participation and access. Staff and friends/supporters of the home organise and promote regular fund raising for the ‘residents fund’, which is used in the promotion of social activities for residents. Religious needs and requirements were also supported. Menus were provided, which provide for a nutritious and balanced diet. Service users spoken with said they enjoyed the food provided and alternatives to the main menu were offered. Drinks and snacks are available at any time. The nutritional requirements of residents are individually assessed and special needs catered for, including dietary, equipment and assistance from staff. Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 the following standard(s): The standards in this section were not fully assessed on this occasion. EVIDENCE: A full inspection of the building was not undertaken on this occasion. The registered manager advised of changes of the use of some rooms in the home, which were being undertaken in order to increase single bedroom provision and upgrade bathing facilities. The Inspector requested that written notification be forwarded to the Commission in respect of these, which details layout plans, room sizes and specifies use. The residents’ communal telephone was not adapted to assist those who may have hearing difficulties – this was raised at the previous inspection for this service (September 2005). Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 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): 27, 28, 29 & 30 Systems and arrangements were in place to ensure that staff were properly recruited, inducted and trained to enable them to effectively support and care for residents. However, there was no system for the individual management supervision of care staff, the provision of which would promote a key measure as to their ongoing efficacy and competency. EVIDENCE: Details of staff employed were discussed, including staff turnover and recruitment of new staff since the previous inspection. Staff duty rotas were also provided and examined and discussions were held about the arrangements for the deployment of staff in the home, which were satisfactory. The ongoing arrangements for staff training were also discussed and records examined, including core health and safety training, NVQ training and other training relating to the conditions of residents and their care needs. These were satisfactory and up to date. Seventy two percent of care staff had achieved NVQ level 2 and a significant number of staff were undertaking recognised distance learning packages in respect of dementia care and infection control. Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 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, 32, 33, 34, 35, 36, 37 & 38. A significant number of satisfactory practises were identified, which promoted and protected the health, safety and welfare of service users. However, these were not underpinned by a formal quality assurance monitoring system or the recording of reviews and action in respect of environmental health and safety auditing and care staff was not receiving individual supervision in accordance with the national minimum standard. EVIDENCE: The registered manager is a registered general nurse who is currently undertaking NVQ level 4 in management. Details of training and development undertaken by her over the previous 12 months were also discussed, together with the management structure, delegation responsibilities and organisation of communication systems and staff in the home. Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 Page 16 At the previous inspection for this service the registered persons had purchased a professional quality assurance and auditing system for the home. This had not yet been operated. Evidence of up to date liability insurance was provided by way of a displayed certificate. There was no written annual development plan provided for the home for the coming year, however, the registered manager advised that she was in the process of formulating a one as part of her NVQ management studies. The arrangements for the management, including safekeeping of residents’ monies were examined and were satisfactory. Discussions were held regarding the arrangements for staff supervision. There was no system in place in respect of the formal individual supervision of staff. A number of records, which are required to be kept in the home, were examined during the inspection. These included the monthly reports of the registered provider regarding her assessment as to the standard of care provided in the home. Records examined were properly maintained and stored. Comments regarding of the arrangements for core health and safety training for staff are made under the staffing section of this report. Certificates for the maintenance of equipment in the home were provided and were up to date. There was a recorded risk assessment in place in respect of the environment, including fire risk assessment, however, this had not been reviewed and updated for almost 2 years and did not reflect any action taken in respect of items recorded as requiring action. The systems and arrangements for the reporting and recording of accidents and untoward incidents in the home were examined and were satisfactory. Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 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 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 3 3 Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 13(2) Requirement Timescale for action 31/10/05 2 OP10 23(2)(n) 3 OP19 37 4 OP33 24 Written policy guidance must be included in the home’s medicines policy in respect the procedure for staff in the event of any verbal order from a GP for the administration of a medicine(s). NB received 150306 The registered persons must 10/11/05 ensure that the telephone provided for service users is suitable for their needs and that suitable adaptations are provided to assist those who may have hearing and/or sight difficulties. NB Info received re tel system – confirms in place 150306 31/03/06 The registered persons must inform the Commission in writing as to the proposed changes of use of rooms and facilities in the home, including details of their location and layout, room sizes and intended use. NB received 150306 The formal quality assurance 31/08/06 monitoring system purchased for the home (or other such suitable system) must be made DS0000002172.V275244.R01.S.doc Version 5.1 Hollybank House Page 19 5 OP36 18 operational. The registered persons must ensure that care staff received formal supervision at least six times per year in accordance with that specified under NMS 36.3 older persons document. 31/05/06 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 OP3 Good Practice Recommendations The revised assessment and care planning format should be completely rolled out to all service users as soon as is reasonably practicable to ensure consistency of approach. NB – From previous inspection – not assessed on this occasion. Individual’s recorded risk assessments should be reviewed at monthly intervals. NB – From previous inspection – not assessed on this occasion. An annual development/business plan should be developed for the home. The recorded environmental risk assessment for the home should be periodically reviewed and updated to reflect any changes. 2. OP7 3. 4. OP33 OP38 Hollybank House DS0000002172.V275244.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 House DS0000002172.V275244.R01.S.doc Version 5.1 Page 21 - 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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