Inspection on 24/01/06 for Hollybank House

This inspection was carried out on 24th January 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 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 19/07/05

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 Lancashire OL13 0RW Lead Inspector Mrs Lynn Mitton Unannounced Inspection 24th January 2006 10:00a Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 DS0000009600.V273414.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 Adults 18-65. 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 DS0000009600.V273414.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hollybank House Address Church Street Stacksteads Bacup Lancashire OL13 0RW 01706 877659 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) Ms Susan Footitt Ms Mary Lorraine Moden Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 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 DS0000009600.V273414.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 6 hours. A partial tour of the premises took place. The registered person, 3 service users and two care staff were also spoken to, and interaction between staff and residents 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 staff member and residents. Records pertaining to these people were examined. Policies and practices were also looked at. There were 4 service users living at Hollybank House at the time of the inspection. The Commission received one comment card from a relative/visitor to the home. The inspector and registered person discussed the recent addition of a conservatory and conversion of the back lounge into another bedroom, with the intention of a 5th resident being admitted on completion of this work. What the service does well: One relative/visitor to the home wrote; “The residents are loved and cared for in a homely environment and this is the best”. The home was run to make sure the service users had opportunities to enjoy their life and to fulfil their potential. Service users had regular access to their local community, and were supported in maintaining family links. Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the service users. Personal support was given to residents in a way that empowered them and promoted dignity and choice. Residents health needs were well documented and how these would be met recorded. Appropriate policies and practices were in place to ensure that residents were safeguarded from the possibility of abuse. The home was well managed, and recruitment records demonstrated efforts to ensure the safety of residents were in place. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 Page 6 The inspector was satisfied that residents were regularly consulted regarding the running of the home. What has improved since the last inspection? 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 DS0000009600.V273414.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 the following standard(s): YA2, YA5 Needs assessments were in place identifying the care needs of residents so that support staff would have a clear understanding of how they needed to support them. Contracts explained what residents could expect, and what was expected of them in order for them to live at Hollybank House. EVIDENCE: There had been no new admissions to the home since the last inspection. The inspector noted that assessments had been undertaken prior to residents admission to Hollybank House and these were considered to be suitable documents to ascertain service users needs prior to admission. Service users contracts were seen. These had been signed and dated by the service user, and fully explained the terms and conditions of their residence at Hollybank House. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 the following standard(s): YA6 & YA9 Lack of some information on care plans meant that resident’s needs were not being recorded accurately to ensure that support staff could meet their needs in a consistent way. Risk assessments were a fundamental element of the residents care plan. Residents were supported in taking responsible risks. EVIDENCE: One residents care plan was examined. This documents contained some information about the level of support needed for staff to ensure continuity of care. The inspector and registered person discussed the content and detail of these plans and how they should be improved. The registered person and inspector also discussed improving the written content, and being more aware of using standard phrases. The care plan had been recently reviewed. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 Page 10 Risk assessments were seen in place. These included information explaining, once the risk had been identified, how it would be managed, and what action was to be put in place to reduce the risk to an acceptable level. One resident said “I love living here” another said, “the staff look after us really well – its great here”. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 the following standard(s): YA13 & YA16 The home was run to make sure the residents had opportunities to enjoy their life and to fulfil their potential. The residents were cared for in a way that promoted choice, dignity respect and fulfilment. EVIDENCE: Each resident had an individual activity programme, which included community-based activities. These also endeavoured to ensure residents had opportunities to fulfil their potential socially, emotionally, and maintain independent living skills. One resident said; “We are going to the Rose & Bowl tonight to play bingo”. By observing interaction between residents and care staff, the inspector was satisfied that privacy, rights and respect were core values held within Hollybank House. Each resident had their own bedroom and most enjoyed spending some time on their own there. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 Page 12 All residents were encouraged to participate in housekeeping tasks to the best of their ability. Residents had access to all areas of the home, except for the office, which was located on the 1st floor, and kept locked when not in use. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 the following standard(s): YA18, YA19 Personal support was given to residents in a way that empowered them and promoted dignity and choice. The health needs of the resident case tracked had been identified and how they would be met, recorded. EVIDENCE: Staff were seen to encourage the service users to be as independent as possible regarding their personal care. Privacy was facilitated and respected. The routines regarding personal care were flexible, and based on each resident’s needs and abilities. The resident case tracked had a health check entitled “My Health Assessment” in place. This was a detailed document and had been recently reviewed. Community nurses had supported the resident and care staff to complete this. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 the following standard(s): YA23 Appropriate policies and practices were in place to ensure that residents were safeguarded from the possibility of abuse. EVIDENCE: Policies and practices regarding the protection of residents from abuse were in place, and seen by the inspector. Staff spoken to had an understanding of adult protection issues, ensuring that any allegations would be passed onto senior staff. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 the following standard(s): YA24 Overall the standard of décor and furnishings provided a comfortable and homely environment for service users. EVIDENCE: The inspector conducted a tour of the homes communal areas. The inspector was noted that since the last inspection a new conservatory had been built, a new kitchen fitted, and the second lounge next to the kitchen was being converted into a 5th bedroom. The inspector was advised that new carpets had been ordered for the staircase and landing and Sky TV had been installed. The home was clean and odour free. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA34 Staff recruitment records, which showed that service users were kept safe, were in place. EVIDENCE: All these standards were looked at during the last inspection. One care staff’s personnel file was case tracked, and it was found to contain all information that demonstrated appropriate checks had been taken to ensure that service users were safeguarded. The inspector was advised that 1:1 meetings were due to be re-established in the near future, and that all staff were due to undertake their Food Hygiene training on 30th January. A new staffing rota had been implemented which clearly showed who was on duty and when. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 Page 17 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA37, YA39 & YA42 The registered person had completed training, which demonstrated that the attitude of the staff and management was to run the home with the needs and safety of the residents as the highest priority. Residents were formally and informally consulted about the running of the home. Further training as identified would ensure the safety and welfare of residents and staff. EVIDENCE: The registered person had completed the NVQ4 qualification in care and management in November 2005. The registered person works “hands on” at the home at least 36 hours each week. Since the last inspection surveys had been conducted with residents in October 2005. The results of this had been published and were seen by the inspector. The inspector and registered person discussed also including residents families and frequent visitors to the home the next time the surveys are completed. Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 Page 18 A business plan had been completed and this was due to be reviewed and a new one developed in the near future. Outstanding from the previous inspection, food hygiene training was planned for 30th January 2006. It was agreed that moving and handling training was not required at Hollybank House. The inspector was advised that other essential health and safety training such as 1st Aid and Infection Control had been planned throughout 2006. Hollybank House DS0000009600.V273414.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 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 3 X X 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hollybank House Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000009600.V273414.R01.S.doc Version 5.0 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. Standard YA6 Regulation 15(1) Requirement Written care plans describing how each residents needs are to be met must be in place. 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 31/03/06 2. YA42 13(4c) 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hollybank House DS0000009600.V273414.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington 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 DS0000009600.V273414.R01.S.doc Version 5.0 Page 22 - 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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