Inspection on 06/06/08 for Hollybank Nursing Home

This inspection was carried out on 6th June 2008.

CSCI found this care home to be providing an Adequate service.

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 Nursing Home 08/08/06

Hollybank Nursing Home 08/02/06

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Hollybank Nursing Home 30-32 Skinner Street Creswell Nr Worksop Nottinghamshire S80 4JH Lead Inspector Rose Moffatt Unannounced Inspection 6th August 2008 09:30 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 Nursing Home DS0000066973.V369851.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 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 Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank Nursing Home Address 30-32 Skinner Street Creswell Nr Worksop Nottinghamshire S80 4JH 01909 721247 F/P 01909 721247 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) Hollybank Nursing Home Limited Mrs M A Dibb Mrs M A Dibb Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: Hollybank is situated in the village of Creswell, near to Worksop, within easy reach of the MI motorway. The home provides personal and nursing care for up to 30 older people. The home comprises two Edwardian period houses joined by a new building link. Accommodation is on two floors in 22 single bedrooms, (12 with en-suite toilets), and 4 shared bedrooms. There is a choice of lounge and dining areas in the home. The first floor is accessed by stairs or a shaft lift. There is a large accessible garden. The fees range from £333.85 to £498.30 per week, depending on assessed needs. The fees include hairdressing and newspapers. This information was provided by the manager on 6th August 2008. Information about the home, including CSCI inspection reports, is available from the manager. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of our inspections is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the provider’s ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: • The annual quality assurance assessment (AQAA) that was completed by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Surveys returned to us by people using the service and from other people with an interest in the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • What other people have told us about the service. We carried out an Annual Service Review (ASR) of the home in December 2007. The ASR looked at all the above information. The ASR showed us that there were some areas of concern about how the home was managed and how this was affecting outcomes for people living there. We carried out an unannounced inspection visit that took place over 7.5 hours on 2 days. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 23 people accommodated in the home on the day of the inspection visit, including 6 people assessed as needing nursing care. People who live in the home, visitors and staff were spoken with during the visit. The manager, Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 6 (who is also the owner of the home), was available and helpful throughout the inspection visit. Some people were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. ‘Case tracking’ was used during the inspection visit to look at the quality of care received by people living in the home. Four people were selected and the quality of the care they received was assessed by speaking to them and /or their relatives, observation, reading their records, and talking to staff. What the service does well: What has improved since the last inspection? What they could do better: Care plans could be improved by ensuring people’s communication, social, cultural and spiritual needs are included. Also, people, and / or their representatives could be more actively involved in planning care. This will help to ensure that people’s needs are met in the way they prefer. The home could be improved by better cleaning and maintenance. This will ensure a more pleasant environment for people living in the home. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 7 Recording and reporting of accidents and other incidents in the home could be improved to ensure people are protected. 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 Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 8 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 Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was sufficient information available and a satisfactory assessment process so that people were confident their needs could be met at the home. EVIDENCE: All people living in the home had individual contracts with the home, stating the terms and conditions of living there. This ensured that the home complied with a requirement made at previous inspections. The AQAA said that people could come for day visits before making a decision about living in the home, and that an assessment of needs was carried out prior to admission. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 10 We looked at the care records for four people living in the home. All of the records included a brief assessment by the home of the person’s needs in relation to activities of daily living. There was assessment information from Social Services and/or hospital staff. There were assessments of the risk of developing pressure sores, the risk of falls, of nutritional needs, and of manual handling needs. All of these assessments had been reviewed monthly up to April 2008. We received two surveys from people living in the home. Both people said that they always received the care and support they needed. We received two surveys from the relatives of people living in the home. One said the home always met the needs of the person, one said the home usually did. People spoken with during the inspection visit said their needs were met at the home. We received surveys from four staff who all said that they received training that was relevant to their role and that helped them to meet the needs of people at the home. Staff spoken with said there was a good training programme at the home. We received comments, and also observed, that the needs of one person were not fully met at the home. The manager was aware of this and had taken steps to address the issues by asking for advice and support from other professionals. Standard 6 did not apply to this home as there were no people receiving intermediate care. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were generally satisfied with the care and support they received. However, care planning, reviews and record keeping were not robust and person centred to ensure that people’s needs and preferences were fully met. EVIDENCE: We looked at the care records for four people living in the home and each had an individual care plan. The care plans had sufficient detail of the action required by care staff to meet people’s needs. Three people did not have care plans about their communication needs, and none of the four records seen had a care plan about the person’s social, cultural and spiritual needs. None of the care plans had evidence of the involvement of the person and / or their representative, although people were involved in care reviews. The care plans had been reviewed monthly up to April 2008. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 12 The daily records gave some information about the person’s needs and any changes, but were generally repetitive and uninformative. The records did not always follow on with information about changes in the person’s needs or condition. For example, a person was reported to have loose stools one day, but there was no further information given on following days so it was not clear that the problem had resolved. In another daily record, the person was reported to have a swollen leg on two days, then no further mention of this. This person was seen by the GP, as noted in the separate records of GP visits, but the findings and treatment were not in the daily records. There were assessments of the person’s continence and any associated support needed, their risk of developing pressure sores, and their nutritional needs. The assessments had been reviewed monthly up to April 2008. One person was assessed as at high risk of developing pressure sores and their care plan said that the assessment should be reviewed monthly. People were referred appropriately for advice and treatment from healthcare professionals, such as GP, District Nurse, chiropodist and optician. One person whose needs had changed had been appropriately referred for specialist advice and treatment. The two people who returned surveys told us they always received the medical support they needed. People spoken with said they could always see their GP when they needed to. The care plans made some references to ensuring people’s privacy and dignity were promoted. Staff spoken with were able to give examples of how to ensure privacy and dignity for people living in the home. Men living in the home who were unable to shave by themselves were shaved in the lounge by staff, allowing no privacy for the men. It was observed that some people in the home had food on their faces and clothes after meals, so that their dignity was not promoted. The two people who returned surveys both said that staff listened to them and acted on what they said. People spoken with said that staff treated them with respect. People said the staff were “like old friends”, “patient and kind”, and “we can have a laugh with them”. Medication was stored securely and was administered by the qualified nurses. The medication administration records seen were correctly completed. There were regular audits and checks by the pharmacist. There were records of medication received into the home, but not of medication disposed of. The Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 13 fridge used to store medication was in need of defrosting. The temperature of the fridge had been recorded daily, but not the minimum and maximum temperatures for each day. The patient information leaflets from packs of medication were kept for reference. There was no up to date reference book about medication for staff to use. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a lack of organised activities and little formal consultation about the lifestyle in the home. It was not clear that the social and recreational needs and preferences of people were fully met. EVIDENCE: We received surveys from two people living in the home. One said there were always activities arranged by the home they could take part in and one said there usually were. The AQAA said the home had tried to create more interest by involving some families in organising activities. The manager said that one relative had recently organised an event with a seaside theme and that this had been enjoyed by people living in the home. There was no plan of activities to let people know what was available for them. Staff said that they encouraged people to join in with activities such as games and singalongs, but that there was not always enough time and interest. When completing the Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 15 Annual Service Review in December 2007, we received comments from three relatives of people in the home that there should be more stimulation and activities. People were consulted about some aspects of life in the home through surveys. No surveys had been carried out in 2008. The care plans seen did not include plans for the social, cultural and spiritual needs of people. People said they could follow their preferred routines. One person said, “I can please myself in what I do and where I go”. Another person said they could get up and go to bed when they wanted to and, “I do what I like”. People said the home was relaxed and homely, and “keeps a very happy atmosphere”. We observed that breakfast time was flexible so that people who wanted to get up later could still have a cooked breakfast if they wanted to. Staff spoken with were clear that people’s preferred routines should be respected. Visitors told as that they were able to visit at any reasonable time and were always made welcome at the home. One relative said they were always met with “friendly greetings with offers of refreshment”. Another relative said staff were always “friendly and welcoming”. Relatives told us the home always kept them up to date with any changes in the person’s health or general condition. One of the people who returned our surveys said they always liked the meals at the home, one said they usually did. There were mixed comments about meals for the Annual Service Review. One person said the “food is excellent and varied”, another said, “some of the meals could be better”. The AQAA said that menus had been changed after consultation with people to include some of their favourite meals. People spoken with during the inspection visit were happy with the meals provided. The lunch served on the day of the inspection visit was well presented and looked appetising. People spoken with said they had enjoyed their lunch. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although people were confident that their concerns would be acted on, there were gaps in recording and reporting that put people at risk. EVIDENCE: The complaints procedure in the main entrance area of the home did not have sufficient information and had out of date contact details for CSCI. The complaints procedure in the office of the home had more information, though still the incorrect contact details for CSCI. The manager said there were no records of complaints as they had not received any. No complaints about the home had been received by CSCI. The people who returned surveys to us all said they knew how to make a complaint. In the Annual Service Review, two people said that they had received responses to complaints made, but the response was not always satisfactory. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 17 People told us they would take any concerns to the manager and they were confident that appropriate action would be taken. People told us they saw the manager nearly every day. We observed that the manager was ‘hands on’ and made herself available to talk to people living in the home and their relatives. There were policies and procedures in place about safeguarding vulnerable adults, including the local multi-agency procedures. Most of the staff had received appropriate training. Staff were clear about what abuse was and said they would go to the manager with any concerns. They were not sure about what procedures the manager should follow, or what procedures should be followed if the manager was implicated. The manager had not informed us of events as specified under Regulation 37 of the Care Standards Act 2000. We must be informed of all deaths in the home, and other events that affect the health and safety of people living there – such as accidents that result in serious injury, allegations of abuse, or incidents where the police are involved. This is to ensure people are fully protected and their health and safety promoted. We made an Immediate Requirement that we must be notified of all relevant events. The Immediate requirement was complied with in the timescale allowed. We wrote to the manager after the inspection visit asking for written confirmation of the action taken to ensure future compliance with Regulation 37. We received a satisfactory response. We found that accidents to people living in the home had not always been recorded properly. Accidents to two people were noted in their daily records with details of the action taken and any treatment given. However, there were no accident forms completed. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although comfortable and homely, the home was not always clean and well maintained to ensure a safe and pleasant environment for people living there. EVIDENCE: Since the last inspection new carpets had been provided for the ground floor corridors, lounges and dining room. Some rooms had been redecorated. There were no security measures at the main entrance of the home so people could walk in without being seen or challenged by staff. Two people had raised this issue at the Annual Service Review. This issue had been discussed previously with the manager and a key-code lock had been installed to the Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 19 door at the top of the stairs so that no-one could get to the first floor without staff assistance. However, this did not fully address the security issues. The door from the main entrance area into the home was propped open on the day of the inspection visit. The manager said this was due to a delivery received that day and removed the item propping open the door. One of the automatic fire doors into the main lounge had a settee against it so that it would not have been able to close when the fire alarms sounded. When this was brought to her attention, the manager moved the settee so that the door could close. Two of the lounges looked cluttered and untidy. One lounge had been redecorated and looked clean and bright. As noted at the previous inspection, the décor in the other lounges and the dining room was tired and dated. The furniture looked worn and many of the chairs and settees were covered in a fabric that was not easy to keep clean and fresh. Several curtains were coming off the rails. The manager took action to remove a television that was not working from one lounge and to have the curtains put back on the rails. The office needed redecoration. The carpet in the office was dirty and was split near to the door, creating a potential trip hazard. There was a hole in the carpet on the first floor corridor, also a potential trip hazard. A bathroom on the first floor was being used for storage of furniture from a bedroom that was being decorated. There had been a water leak to the ceiling of the bathroom and the damaged area needed redecorating. The AQAA said that there was a continuing programme of redecoration in the home. The manager said that bedrooms were always redecorated when they became vacant. The two people who returned surveys, and some people spoken with said the home was always clean and fresh. Other people told us that the home was “not always as clean as it should be”, and, “it could be tidier”. We observed that the home was generally in need of cleaning. For example, windows and windowsills were dirty, carpets had lots of ‘bits’ on them and the carpet outside the hairdressing room had a trail of hair cuttings (the inspection visit was two days after the hairdresser had been). The laundry was suitably equipped and there were satisfactory sluice facilities. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 20 The AQAA said that all staff at the home had received training about infection control. Staff spoken with confirmed that they had received training. Staff were aware of infection control procedures. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by a well motivated and competent staff team in sufficient numbers to ensure their needs could be met. EVIDENCE: The staff rotas showed that there were usually three or four care assistants on duty from 8am to 3pm, plus a qualified nurse or the manager. There were usually three care assistants from 3pm – 10pm, plus a qualified nurse. There were two care assistants plus a qualified nurse for the night shift. In addition to the care staff, there were kitchen, laundry and domestic staff. The AQAA said that no staff had left the home in the previous twelve months and that no shifts had been covered by temporary staff. The manager said there was very little staff turnover and that many staff had been working at the home for 5 years or more. People told us in the surveys and when we spoke to them that there were always enough staff available to meet their needs. There were mixed views Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 22 from staff. From the surveys and those we spoke with, three staff said there were always enough staff, one said there usually were, and three said there sometimes were. Staff told us that staffing levels were increased when there were more people living in the home, or if someone needed additional help. We observed that there appeared to be sufficient staff available on the day of the inspection visit to meet people’s needs. The AQAA said that fifteen (of twenty) care assistants had achieved National Vocational Qualification (NVQ) Level 2 or above (75 ), and another five were working towards the qualification. The home had exceeded the National Minimum Standard level of 50 of care staff with NVQ Level 2 or above. The manager said that no new staff had been recruited since the last inspection in 2006. We looked at the records of three staff who had all been working at the home for more than five years. The records included nearly all the required information, except for proof of their identity. There were no recent staff induction records to see as there had been no new care staff recruited for at least two years. Staff told us that their induction had covered everything they needed to know when they started the job. Staff said that there was a good programme of training that helped them to meet people’s needs. One member of staff said they “have lots of in house training every year”. Staff said the training was good quality, but was sometimes of limited use where updates were the same training repeated year after year. Staff were responsible for keeping their individual training files up to date. Most staff had received training about dementia and challenging behaviour in addition to the required statutory training. The AQAA said “We have a highly motivated staff team with good staffing levels and training”. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were lapses in recording and reporting, and a lack of development of the quality assurance system so that the safety, welfare and best interests of people were not promoted. EVIDENCE: The manager was also the owner of the home and a qualified nurse. She had achieved the Registered Manager’s Award in 2006. Most people said they found the manager approachable and were confident she would take appropriate action on any concerns raised. One member of staff said, “We can Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 24 meet with matron to discuss any problem if needed”. One person said they found the manager difficult to approach. The AQAA had not been returned prior to the inspection visit as required. During the inspection visit, we found that the manager had not completed the AQAA. An Immediate Requirement was made for the manager to complete and return the AQAA to us two days after the inspection visit. The manager complied with this requirement. The information in the AQAA was brief and gave us little information about the home. Some areas of the dataset were not completed. The quality assurance system included surveys given to people living in the home. Surveys were last carried out in 2007. There was no analysis of the results or report of the action taken to address any issues raised. Staff said they were regularly asked for their opinions and feedback about the service. They said they were kept informed by the manager of any changes in people’s needs or to the home. Staff said they did not have formal supervision by the manager. The manager said that no personal money was held by the home for people living there. Records relating to the fire alarm system and equipment were generally satisfactory. Records of fire drills did not include details of the staff involved, if the correct procedures had been followed, and any action was needed to ensure future safety of people. The electrical and gas safety certificates were both out of date. The manager said that both had been recently renewed, but new certificates had not been sent to the home. There were gaps in reporting and recording that put people at risk. (See Complaints and Protection section of this report). Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 25 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A X X 2 Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 26 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 Standard OP7 Regulation 15(1) Requirement Timescale for action 31/10/08 2 OP9 13(2) 3 OP19 23(2)(b) 4 OP19 23(2)(d) Each person living in the home must have a care plan that includes all their assessed needs, specifically, their communication, social, cultural and spiritual needs. This will ensure that people’s needs are fully met. Records must be kept of all 30/09/08 medication disposed of. This will ensure people are protected by safe disposal of medicines and by a good audit trail. The home must be kept in a 30/11/08 good state of repair, specifically: • the office carpet and the identified carpet in the first floor corridor must be repaired or replaced to ensure there is no trip hazard. • the first floor bathroom ceiling must be repaired and redecorated where there has been a water leak. This will ensure a well maintained environment for people living in the home. All parts of the home must be 30/09/08 DS0000066973.V369851.R01.S.doc Version 5.2 Hollybank Nursing Home Page 27 5 OP29 19(1)(b) 6 OP33 24(2)(3) (4) 7 OP38 37 8 OP38 17(2)(3) (4) 13(4)(c) 9 OP38 kept clean to ensure a safe and pleasant environment for people living there. Each person employed at the home must have proof of identity. This will help to ensure a robust recruitment procedure to protect people living in the home. The Annual Quality Assurance Assessment must be completed and returned to CSCI when requested. This will ensure that the home evaluates the quality of care provided so that people know the home is run in their best interests. Immediate Requirement CSCI must be notified without delay of the occurrence of deaths, illnesses and other events as specified in the regulations. This is to ensure people are protected. Immediate requirement Records must be kept of any accident that occurs in the home. This will help to protect people living in the home. There must be up to date safety certificates in respect of the electrical and gas systems in the home. Copies of the current certificates must be sent to CSCI. This will help to ensure the safety of people living in the home. 31/10/08 08/08/08 08/08/08 30/09/08 30/09/08 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 Good Practice Recommendations DS0000066973.V369851.R01.S.doc Version 5.2 Page 28 Hollybank Nursing Home 1 Standard OP7 2 3 OP7 OP9 4 5 OP12 OP16 6 OP19 7 8 OP27 OP33 9 OP38 People living in the home, and/or their representatives, should be more actively involved in the planning and review of care. This will help to ensure that care is provided in the way people expect and prefer. Care plans should be reviewed at least every month to ensure that people’s changing needs are monitored and fully met. The daily minimum and maximum temperatures should be recorded for the fridge used to store medication and the fridge should be regularly defrosted. This will ensure that medicines are stored correctly to avoid any deterioration. The programme of activities should be developed so that all people in the home are offered opportunities to meet their social and leisure needs. The complaints procedure displayed should be updated to include the correct address for CSCI. This will ensure that people have the information they need if they want to raise concerns. There should be security measures at the main entrance so that staff are always aware of visitors coming into the home. This will ensure that people in the home are fully protected. There should be more administrative support for the manager. This would benefit people by ensuring better organisation of the home. An annual report of the quality assurance surveys should be made available to people living in the home and their representatives. People will be assured that their views are taken seriously and that the home is run in their best interests. Records of fire drills should include the names of staff / others who took part, any issues arising, and the action taken to address the issues. This will help to ensure people are protected. Hollybank Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Nursing Home DS0000066973.V369851.R01.S.doc Version 5.2 Page 30 - 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. 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