Inspection on 19/07/05 for Hollybank House

This inspection was carried out on 19th July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollybank House 25/09/07

Hollybank House 20/02/07

Hollybank House 24/01/06

Hollybank House 25/01/05

Hollybank House 09/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Hollybank House Church Street Stacksteads, Bacup, Rossendale, Lancashire OL13 0RW Lead Inspector Lynn Mitton Unannounced 19 July 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hollybank House Address Church Street Bacup Rossendale Lancashire OL13 0RW 01706 877659 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) Ms Susan Footitt Ms Mary Lorraine Moden Care Home Only Personal Care (PC) 4 Category(ies) of Learning disability (LD) 4 registration, with number of places Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25 May 2005 Brief Description of the Service: Hollybank House is registered with the Commission for Social Care Inspection to provide personal and social care for up to 4 adults with a learning disability aged over 18 years. At the time of the inspection there were four people accommodated. The home is a terraced property located off a busy main road, on the outskirts of Stacksteads. Rawtenstall town centre is approximately four miles away in one direction Bacup approx 1.5 miles in the other. The home offers 4 single bedrooms, one being en-suite. There are two lounges. The home is tastefully decorated and maintained to a high standard throughout. The proprietor aims to offer a homely environment within structured and consistent guidelines. Hollybank House has been open since 1998. Service users are Local Authority funded. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately 8 hours. There were 4 residents accommodated at this time. A tour of the home took place. The building of a new conservatory adjacent to the home was still at the planning stage, but was being actively pursued by the registered person. Over the course of the inspection the staff on duty, plus the registered person was spoken to, 2 residents spoke to the inspector and interaction between the service users and staff members were observed. Throughout the report there are various references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of service users. Records pertaining to these people were inspected. Policies and practices were also read. Two resident relatives had completed the Commission’s comment card, and four residents had completed the service users survey. These indicated that overall they were very happy with the level of service received at Hollybank House. What the service does well: What has improved since the last inspection? Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 6 Seven of the eight care staff had completing NVQ 2 and 3 training to help them meet the needs of service users. All the care staff team had completed accredited training to ensure that medication was administered safely. 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 F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5 EVIDENCE: There have been no new admissions since the last inspection. On the residents care plan case tracked, there was no evidence of a contract, explaining the terms and conditions of their residence at Hollybank House. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 The care and health needs of service users were identified and documented. Service users individual needs were know by staff. Service users were encouraged to make day-to-day decisions about their lives. EVIDENCE: The inspector looked at one residents care plan. On it was some information identifying the resident’s care and health needs. The inspector and registered person discussed how, once residents needs had been identified on the assessment of needs document, the care plan must explain how these needs are going to be met by the care staff team. The registered person agreed to implement such information. There were risk assessments on the residents care plan. The inspector identified at least one risk assessment that should be in place for the resident’s case tracked. The resident’s activity sheet should be dated and regularly reviewed. Daily records seen gave a good account of events and activities undertaken during each day. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 10 Whenever possible, service users were given information and options to help them make positive decisions about their own lives. From observations the inspector felt that staff knew resident’s needs very well. Residents spoke highly of the care given to them by the staff team. One relative of a resident to the home commented, “I value Hollybank House and all staff, since my relative was placed there the change has been amazing”. Another said “my relative is extremely settled due to staff being so caring at all times, and I am always made to feel welcome when I drop in”. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15 & 17 The home was run to make sure the service users enjoyed their life and had opportunities to fulfil their potential. Service users had regular access to their local community, and had opportunities to maintain family links. Individual dietary needs were catered for with care and sensitivity. EVIDENCE: Each resident had a daily activity programme. The resident had such a programme in place, however this had not been dated or recently reviewed. Activities undertaken included using local community and sport facilities. Residents had all been on or had a holiday planned in the near future. One resident’s family member said, “ My relative has never been on as many outings and holidays”. A resident told the inspector “we go out all the time”, and another said “we’re going to Blackpool in the caravan this weekend” and “we go to the Rose and Bowl and play Bingo”. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 12 Residents were able to keep in regular touch with their families and friends, by ‘phone and regular visits. One residents family member confirmed that “we are always in contact”. There were no set menus in place. A record of food eaten was kept. Often different meals were served at any one mealtime. One resident was on a reducing diet and the staff were very supportive regarding this. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Service users health needs were being attended to, however documentation put in place to ensure that all elements of each person’s healthcare needs were being met must be completed for all residents. Good practice was in place with regards to the administration, safekeeping, storage and disposal of residents medication. EVIDENCE: There was information on the care plan regarding the residents’ health care needs An “OK healthcheck” document was in place, and most staff had undertaken training to complete this document. However the resident case tracked did not have one in place. Two residents were regularly taking medication. The administration and storage was found to be in good order. The registered person and inspector discussed recent difficulties with the supplying pharmacist and how these had been resolved. All staff had completed training to ensure that they administer medication safely. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 There were clear complaints policies and practices in place. Staff spoken to had a good understanding of dealing with complaints made by service users. EVIDENCE: There was written documentation in place regarding complaints. There had been no complaints made since the last inspection. Staff spoken to could satisfactorily explain to the inspector what they would do if a complaint was made to them. Residents spoken to could also tell the inspector what they would do if there was anything they were not happy with. It was acknowledged that these residents were very assertive and would not hold back in expressing themselves if they were unhappy. Residents also had an opportunity to comment on and contribute towards the running of the home at residents meetings. The last residents’ meeting was held in February 2005. The last residents survey was held in September 2004. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 The standard of décor and furnishings provided a comfortable and homely environment for residents. The standard of cleanliness and hygiene in the home was good. EVIDENCE: The furnishings and fittings were compatible with the needs of the service users. The building of a new conservatory adjacent to the home was still at the planning stage, but was being actively pursued by the registered person. The re-decoration of one residents bedroom, the replacement of the stairs and landing carpet and a newly fitted kitchen was also planned before 2006. The home was clean and tidy, and there were no offensive odours. A new Control of Infection Policy had been introduced. The inspector and registered person discussed the covering of bare light bulbs in the staff office (a potential fire hazard) and the tidying of the overgrown front garden shrubs. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34 & 35 Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the service users. Regular 1:1 supervision would ensure that each staff member was clear about what was expected of them. Almost all care staff had undertaken NVQ training which enable them to better meet the needs of service users. EVIDENCE: Full documentation regarding the recruitment of staff would demonstrate the intention to safeguard service users. The inspector noted that out of the care staff team of 8, 4 care staff members had completed their NVQ level 3 training, and 3 had completed their NVQ level 2 training. As previously mentioned, Administration of Medication and Health Action Planning training had also been completed. Further training was planned in September entitled “Dealing with Dementia”. The training matrix needed revising and bringing up to date. The inspector case tracked 1 employee file, most of the information required was available to the inspector. Proof of identity for this staff member was not on the file. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 17 There was evidence that team support meetings took place with the registered person. The development of supervising individual staff members was discussed. The inspector observed service users being supported by competent staff. Staff spoken to by the inspector talked about the importance of working closely together and how they valued the support they received from each other as a staff team. The staff rota was seen and how this could be improved to make it more easily to understand was discussed. There were at least two care staff members on duty at any time, and two staff sleeping in overnight. There was a 20-hour care staff vacancy. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Staff training must be completed to ensure the health safety and welfare of service users and staff are safeguarded. EVIDENCE: The inspector noted a number of up to date safety certificates issued with regard to the routine maintenance and safety of Hollybank House. Staff spoken to could describe what to do in the event of a fire. Training issues regarding safe working practices were identified as outstanding for some staff, for example 3 staff had not done 1st Aid, 2 staff had not done moving and handling, and 2 had not done food hygiene training. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 x 3 Standard No 31 32 33 34 35 36 Score x 4 x 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hollybank House Score 2 x x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 20 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. 2. Standard YA5 YA6 Regulation 5(1b) 15(1) Requirement All residents must have a contract in place Written care plans describing how each residents needs are to be met must be in place. Risks must be identified and assessments completed to ensure that residents are so far as is practible free from avoidable risks. Documentary evidence as described in Schedule 2 of the Care Home Regulations must be kept at the home and be available to the inspector. Risks to service users health and safety are identified and so far as possible eliminated, in that all staff receive appropriate training. Timescale for action 11th November 2005 11th November 2005 11th November 2005 3. YA9 13(4c) 4. YA34 sche 2 11th November 2005 5. YA42 13(4c) 16th December 2005 Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 21 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 YA18 Good Practice Recommendations OK Health checks should be completed and updated for each resident. Hollybank House F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. BB5 5JB 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 F57 F07 S9600 Hollybank House V231192 190705 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!