Inspection on 25/09/07 for Hollybank House

This inspection was carried out on 25th September 2007.

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 20/02/07

Hollybank House 24/01/06

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 25th September 2007 10:00 Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 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.V345097.R01.S.doc Version 5.2 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.V345097.R01.S.doc Version 5.2 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 Sue Footitt Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate up to a maximum of 5 service users in the category of LD (learning disability) 20th February 2007 Date of last inspection 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 5 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 5 single bedrooms, two being en-suite. There is one lounge and one conservatory. 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 opened in 1998. Residents are Local Authority funded. Fees for the cost of a weeks care at Hollybank House range from £450.00 and £500.00. There was information available to potential residents advising them of the home and giving them details about the type of service they could expect. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 25th September 2007. There were 3 people accommodated at this time. A tour of the communal areas of the home took place. Over the course of the inspection 2 of staff on duty were spoken to, and interaction between the residents and staff members were observed. An expert by experience accompanied the inspector on the visit. An expert by experience is a person, who because of their experience and ability to communicate with people visits a service with the inspector to help them to get a picture of what it is like to live in or use the service. The expert by experience was involved to help the inspector determine whether people’s social needs and expectations were being met. Aspects of his findings were included in the report. Throughout the report there are references to “case tracking”, this is a method whereby the inspector focuses on a small representative group of people using the service and care staff. Records regarding these people were inspected. Policies and practices were also read. Two residents relatives had completed the Commission’s “Have your say” comment card, and these indicated that they were very satisfied with the level of service at Hollybank House. What the service does well: One person using the service told the expert by experience that the staff were good, and she going to Scotland for her holiday on Thursday. The residents have had the same staff for a long time. Another person using the service told the expert by experience; “The staff are very good. I get out a lot. I like activities, shows, music, writing my own jokes, and planning menus for meals”. When asked; “what do you feel the care home does well?” one relative wrote; “Creates a family atmosphere”. They then went onto write “My relative is not the easiest person to deal with, but the patience, love and care shown at Hollybank House is second to none, and I could not wish for a better place”. Residents were supported in taking responsible risks and independence was promoted to the best of individual ability. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 6 The home was run to make sure that people had opportunities to enjoy their life and to fulfil their potential. People using the service were able to make day-to-day decisions about their lives, and had opportunities to fulfil their potential. Resident’s health and medication needs were appropriately recorded; this should ensure that care staff knew how people’s needs were to be met. The standard of décor and furnishings provided a comfortable and homely environment for people living at Hollybank House. The attitude of the staff and management was to run the home with the needs of the residents as the highest priority. What has improved since the last inspection? What they could do better: Minor amendments should be made to ensure the complaints policies and procedures contain up to date information. Evidence that the smoke detectors are being tested should be documented when tests are completed. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 8 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.V345097.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA2 & YA5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Needs assessments were now in place for people using the service; identifying their needs so that support staff would have a clear understanding of how they could support them. Up to date contracts were in place, explaining what people 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 evidence of an assessment of need was in place for the person case tracked. A contract containing information about terms and conditions in respect of accommodation to be provided including the amount and method of payment of fees could be found for the resident case tracked. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA6 YA7 & YA9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information on care plans enables support staff to meet resident’s needs in a thorough and consistent way. Residents were supported in taking responsible risks and independence was promoted to the best of the individuals ability. EVIDENCE: One care plan was examined. There was good information about the level of support needed for staff to ensure continuity of care. There was now a photograph on the file. Daily records were seen and their content was good. The care plan had been reviewed within the past month. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 11 Four risk assessments were seen on the care plan. 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. Two people using the service told the expert by experience that they managed their money with staff support. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA12, YA13, YA15, YA16, YA17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run to make sure that people had opportunities to enjoy their life and to fulfil their potential. People using the service were able to make day-to-day decisions about their lives, and had opportunities to fulfil their potential. Individual dietary needs were catered for. EVIDENCE: One person using the service told the expert by experience; “I go Bowling, Bingo, Pub, Power walking, and pictures, and I ring my Mum often and visit her every other week”. One person using the service told the expert by experience; “I like Eggs, Chips, and Sausages”. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 13 When asked; “does the care home help your relative to keep in touch?” one relative wrote; we are in touch all the time”. They then went on to write; “Whenever we visit we are always made welcome and all enjoy a cup of tea and a natter together”. People using the service had regular access to their local community; and activities accessed within the local community included the local supermarket, Gateway social club and local pubs for bingo/drink/meals. Each resident had an individual activity programme, which included community-based activities. The inspector noted that the person case tracked had an up to date activity programme in place. Residents usually had access to a vehicle, which they used to access the wider community. The inspector was advised that no residents expressed a wish to attend church. The inspector noted that one person was due to go to Scotland for a holiday and two others were going to Pilling in a caravan in the next few weeks. The inspector observed residents being spoken to with respect and support staff were also observed respecting residents rights and wishes. A record of food eaten by residents was kept, as there was not a set menu in place. Staff encouraged residents to help prepare food in the kitchen under staff supervision. An environmental health food inspection had taken place in February 2007. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA18, YA19 & YA20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and medication needs were appropriately recorded to ensure that care staff knew how people’s needs were to be met. EVIDENCE: Care staff were seen to encourage the residents 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 person’s needs and abilities. The person case tracked had a health assessment review document dated April 2007. There was also information on file about recent optical care. Policies and practices for managing and administering medication were in place. Medication was administered using the Nomad Monitored Dosage System. Residents had their medication administered by care staff. Patient Information leaflets were in place. Administration records seen were completed correctly. Most staff had completed training to ensure that they administer medication safely. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA22 & YA23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and protection policies were in place. Staff had completed protection of vulnerable adults training. EVIDENCE: One person using the service told the expert by experience; “I attend a Client and Staff Meeting every six weeks, where any issues can be discussed. If I had any problems I would complain to staff or the manager”. One person’s relative wrote; “I have never had any cause for concern about my relative’s care”. There had been no complaints since the last inspection. The complaints policy and procedure was seen. A complaints procedure had been developed in a format that may be understood by people using the service i.e. in a pictorial format. Minor amendments were needed e.g. the Commissions new address, and the wording regarding being able to contact the Commission at anytime. Staff had now undertaken prevention of abuse training. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA24 & YA30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor and furnishings provided a comfortable and homely environment for people living at Hollybank House. EVIDENCE: The inspector conducted a tour of the homes communal areas, and noted that the new conservatory was being well utilised. The inspector was advised that a new staircase and landing carpet was being fitted later that week. A new microwave had been bought recently. The home was clean, tidy and odour free. Suitable laundry facilities were in place. No specialist adaptations were needed. An environmental health officer visited Hollybank House in June 2007 and there was a “making food safely” folder in place. Fridge and freezer temperatures were being recorded regularly. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA32, YA34 & YA35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 80 of care staff had completed NVQ training, which enable them to better meet the needs of residents. Regular 1:1 supervision ensured that each staff member was clear about what was expected of them. Recruitment and selection procedures protect people using the service. EVIDENCE: The inspector noted that out of the care staff team of 5, 4 care staff members had completed their NVQ level 3 or NVQ2 training. 1:1 supervision with staff was diarised at 6 weekly intervals, and team meetings every 8 weeks. Records showed that the member of staff case tracked had had regular supervision an appraisal and a training development review. Minutes from two team meetings in March and July were seen. One member of staff’s file was case tracked and this was found to contain information needed to demonstrate that they protected residents. A training matrix had been updated, this indicated that training had recently taken place, and more was planned for November 2007. Evidence was seen Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 18 on the staff members case tracked of training, this included; health and safety in the workplace, food hygiene, safe handling of meds, Emergency 1st aid, Infection control. The inspector noted that a basic induction checklist was in place, and advised that LDAF induction and foundation training must be available to new all staff. The inspector observed residents being supported by competent staff, and there were at least two care staff members on duty at any time, and two staff sleeping in overnight. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA37, YA39 & YA42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The attitude of the staff and management was to run the home with the needs of the residents as the highest priority. Residents were now formally consulted about the running of the home. EVIDENCE: The registered person had undertaken appropriate training, and works “hands on” at the home at least 36 hours each week. Since the previous inspection, the practice manager had now left Hollybank House. Resident’s, relatives and staff surveys had been conducted in April 2007. The visitor’s book was now being completed. Residents meetings had taken place in March and August 2007 and records were seen. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 20 The inspector noted a number of up to date safety certificates issued with regard to the routine maintenance and safety of Hollybank House. Staff had now completed food hygiene, health and safety and safe handling of medication training. The inspector advised that evidence should be demonstrated that the homes smoke detectors are being tested. Training issues regarding safe working practices had been completed in protection of vulnerable adults, fire safety and 1st Aid and planned for Infection Control in November. Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 21 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 Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Hollybank House DS0000009600.V345097.R01.S.doc Version 5.2 Page 22 No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA22 YA42 Good Practice Recommendations Minor amendments should be made to ensure the complaints policies and procedures contains up to date information. Evidence that the smoke detectors are being tested should be documented when tests are completed. 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