Inspection on 20/09/05 for Hollybank House

This inspection was carried out on 20th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hollybank House 19/02/09

Hollybank House 28/02/07

Hollybank House 20/07/06

Hollybank House 14/02/06

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 Sue Richards Unannounced Inspection 20th September 2005 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.V252441.R01.S.doc Version 5.0 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.V252441.R01.S.doc Version 5.0 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.V252441.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 20 places for PCN - Not to exceed 4 places for PD over 50 years which are included within the PCN registration 30th March 2005 Date of last inspection 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.V252441.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? The revised format for the formulation and maintaining of service users care planning records, including that relating to assessment has been introduced for a significant number of service users. Staff induction has been rolled in accordance with recognised standards. A review of the arrangements for training and instruction for staff in relation to moving and handling, particularly new staff starters is underway with planned dates for the manager to undertake training for trainers. Lockable storage is provided for service users in all bedrooms. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 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.V252441.R01.S.doc Version 5.0 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.V252441.R01.S.doc Version 5.0 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): 3&4 The introduction of the revised needs assessment and care planning documentation promotes a more comprehensive and person centred approach to care delivery in the home. EVIDENCE: The care of three service users was case tracked. Discussions were held with those service users who were able about their care needs and also staff who cared for them in the home. Recorded individual needs assessment documentation was also examined and records related to the admission process. At the previous inspection for this service undertaken in March 2005, a revised format for the recording of individual needs assessment information had begun to be introduced for all service users. Two of the three service users case tracked had the revised format in place detailing comprehensive and up to date information in respect of their assessed needs, including detailed Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 9 information relating to their daily living preferences. One of the service users case tracked did not have the revised documentation in place, although this was planned. There was no daily living plan in place for that person which detailed their personal preferences in respect of this. Discussions with this service user were held which indicated that whilst his basic care needs and independence was well promoted and met, some aspects of personal choice were sometimes overlooked in relation to daily living preferences. Two of the service users case tracked had clearly identified specialist needs which were well accounted for. Care spoken with was conversant with the needs of those service users. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 There were satisfactory systems and arrangements in place to ensure that service users health care needs are met, although the lack of a clearly written medicines policy relating to a verbal instruction from a GP promoted inconsistent practise. EVIDENCE: Documented care plans were in place for each of the service users case tracked, which were formulated in accordance with their individual risk assessed needs, although some did not have reviews recorded at monthly intervals. Specialist needs and required care interventions were clearly documented and were in accordance with recognised professional and clinical guidelines. Due to their given capacities and specialist needs, staff were unable to involve and obtain the active agreement of two of the service users case tracked in their care plans. The third service user case tracked, did not have the revised needs assessment and care planning documentation in place and had not been involved in the formulation of his care plans or a daily living plan. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 11 The health care needs were well documented for each service user case tracked (including personal and oral hygiene needs) and there was a recognised approach to clinical risk assessment and care and treatment, including that relating to pressure ulcers, falls, nutrition, moving and handling and mobility needs and continence. The arrangements for service users to access their GP and other outside health care professionals was discussed with staff and service users and records examined. The arrangements for the promotion of physical activity and exercise were also discussed and were satisfactory. Service users spoken with enjoyed the regular physical activity sessions provided. The arrangements for the management and administration of medicines for those service users case tracked were examined. Overall these were satisfactory, although there was no written policy guidance in place for the event of medicines to be administered on the verbal instruction of a GP. For one of the service users case tracked, a written record of such a verbal instruction did not have the signatures of two staff. The Inspector spoke with the nurse in charge regarding the required procedure, who confirmed that two signatures were required. Staff was observed to be mindful of service users needs and respectful in their approaches. The telephone, which is provided for service users own use did not have any adaptations to assist those service users with hearing problems or sight difficulties. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 12 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): The standards in this section were not assessed on this occasion. EVIDENCE: Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The were satisfactory systems and arrangements in place to enable service users and their representatives to complain and to promote the protection of service users from abuse. EVIDENCE: Three complaints had been received by the home since the previous inspection, which were investigated via recognised joint agency adult protection procedures as reported by the manager. Records were in place in relation to these complaints, together with details of outcomes, evidence and action taken. There is a recognised complaints procedure, which is provided for service users and their representatives. This is openly displayed and provided by way of the service user guide. Arrangements for staff training and instruction in relation to adult protection were examined and were satisfactory. Staff spoken with was conversant with recognised procedures in respect of this. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 14 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 home is generally well maintained and decorated and furnished to a reasonable standard, although service users would benefit from identified areas of upgrading, repair and renewal. Environmental hazards identified during the inspection were potential risks to service users. EVIDENCE: A tour of the building was undertaken. The environment is homely and areas seen were clean well maintained and decorated and generally well furnished and suitably lit and ventilated. However, some easy chairs were well worn and ready for replacement. The Manager and owner were not present to discuss any planned upgrading, repair or renewal for the home and there was no written plan available. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 15 The door to bedroom 17, which was a fire door, was propped open with a commode seat. The Inspector observed cleaning substances to be left out openly around the home. The nurse in charge removed these and placed them in locked cabinets provided. The fire to the lounge dining room did not have a guard provided. There was no risk assessment in place in relation to this. A number of bathrooms and toilets were inspected. One of the toilets to the ground floor extension had a very wet floor. The Inspector was advised that this was due to a leak, which the maintenance person was aware of. However, the door had been left open and there was no warning sign as to the potential slipping hazard for service users. The toilet in the bathroom opposite bedroom 23 on the extension was positioned on a raised platform, which posed difficulties for use by service users given its height from the floor. The shower room located on the ground floor of the older part of the building was used for storage of chairs and other items and was out of use due to drainage problems. Although laundered at high temperatures between use, communal flannels were provided for intimate personal hygiene. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 16 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 There were satisfactory arrangements in place to ensure adequate and sufficient staffing of the home on a daily basis and also for the induction and training of staff employed. Recruitment practises did not fully comply with requirements. EVIDENCE: Details of staff employed were provided by way of the pre-inspection questionnaire, together with details of staff turnover and recruitment. Staff duty rotas were also provided and were examined during the inspection and the personal files two more recent staff starters were examined. The number and skill mix of staff on duty at the time of the inspection was satisfactory and staff duty rotas indicated the provision of adequate staffing. Staff spoken and service users spoken with felt that staffing arrangements were satisfactory. Serious concerns were raised during the inspection and also separately in writing to the registered provider in relation to the recruitment process as understood and undertaken by the home, which did not always comply with legal requirements. Written details of action to be taken by the registered persons in respect of this was also provided during the inspection. The Inspector will monitor compliance with this. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 17 Written details of staff training undertaken during the past 12 months were provided in the pre-inspection questionnaire, together with details of training planned and also the NVQ training status of all care staff. Staff records sampled was reflective of these as were discussions with staff. The arrangements for staff induction were also examined and discussed with staff and were satisfactory. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 18 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): The standards in this section were not assessed on this occasion. EVIDENCE: Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 19 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 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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 OP7 OP9 Regulation 15(1) & (2)(a) 13(2) Requirement Service users must be consulted about their care plans, which must be made available to them. 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). The registered persons must 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. POVA checks must be undertaken by the home for all new staff starters and criminal records checks as stated. NB Immediate requirement issued in writing during inspection – reg person to advise commission in writing of intended action by stated date. Fire doors must be kept closed at all times or fitted with suitable closing devices, which ensure that they close automatically in DS0000002172.V252441.R01.S.doc Timescale for action 30/11/05 31/10/05 3 OP10 23(2)(n) 10/11/05 4 OP29 9 28/09/05 5 OP19 23(4)(a) & (c)(i) 31/10/05 Hollybank House Version 5.0 Page 21 6 7 OP26 OP28 13(4)(a) & (c) 18(1)(a) & (c) the event of a fire. Cleaning materials, which may be hazardous to health must be safely stored at all times. At least 50 of care staff must have achieved or be working towards NVQ level 2 by 2005. 30/09/05 31/12/05 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 2 3 Refer to Standard OP3 OP7 OP28 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. Individual’s recorded risk assessments should be reviewed at monthly intervals. The registered person should consider the benefits of a second staff member accessing the training for trainers course in relation to moving and handling instruction for staff in order to provide consistency and timely and focused training for staff. Hollybank House DS0000002172.V252441.R01.S.doc Version 5.0 Page 22 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. 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