Inspection on 08/08/06 for Hollybank Nursing Home

This inspection was carried out on 8th August 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 but made no statutory requirements on the home.

Other inspections for this house

Hollybank Nursing Home 06/06/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hollybank Nursing Home 30-32 Skinner Street Cresswell Nr Worksop Nottinghamshire S80 4JH Lead Inspector Rose Veale Unannounced Inspection 8th August 2006 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 Nursing Home DS0000066973.V305891.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.V305891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank Nursing Home Address 30-32 Skinner Street Cresswell Nr Worksop Nottinghamshire S80 4JH 01909 721247 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 Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 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 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 an accessible and attractive garden. The home provides personal and nursing care for up to 30 older people. The fees range from £298.20 to £467.90 per week, depending on the level of care required. The fees include hairdressing and newspapers and do not include chiropody or personal toiletries. (Information regarding fees was obtained from the owner/manager on 08/08/06). Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5½ hours. There were 28 residents accommodated in the home on the day of the inspection, including 9 residents assessed as needing nursing care. Residents, visitors and staff were spoken with during the inspection. Some residents 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. The owner/manager was available and helpful throughout the inspection. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. What the service does well: What has improved since the last inspection? What they could do better: Residents had not been provided with the terms and conditions of residing in the home and so could not make an informed choice about living in the home. There were areas of the home where the décor appeared ‘tired’ and worn. Some of the carpets were stained and worn. It was observed during the inspection that wheelchairs were used without the footplates in place and tipped back to avoid the residents’ feet catching on the floor. This had been observed at the previous inspection and discussed with the manager as a potentially unsafe practice. At this inspection further Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 6 discussion took place and the manager was advised to carry out risk assessments for residents who chose to use wheelchairs without footplates or where the use of footplates could possibly cause injury. 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 Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 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 Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 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): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents did not receive all the information they needed to enable them to make an informed choice about living in the home. The assessment process was good so that residents were confident the home could meet their needs. EVIDENCE: A requirement was made at the previous inspection that all residents must have an individual copy of the terms and conditions of living in the home. A copy of the terms and conditions was seen. This needed minor amendments regarding what was included in the fees and a breakdown of the Registered Nursing Care Contribution where applicable. The requirement has been carried forward in this report as residents had not been issued with individual terms and conditions. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 9 The records of 4 residents were examined, 2 residents requiring personal care and 2 requiring nursing care. All the records seen had assessment information obtained prior to the resident moving to the home including the hospital assessment and community care assessment. The home’s assessment information included brief details of medical and social history and a brief assessment of the residents needs related to the activities of daily living. There were assessments of the risk of developing pressure sores, the risk of falls, nutritional needs, and manual handling needs. All these assessments had been reviewed and updated monthly. Care plans had been produced from the assessment information. Residents and their relatives spoken with said the home was able to meet their needs. Standard 6 does not apply to this service. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Individual care plans did not always contain enough detail to ensure that residents’ health and personal care needs were fully met. EVIDENCE: The 4 care records seen each included a care plan. 2 of the care plans seen did not include all the assessed needs of the residents. For example, 1 resident had been assessed as being at a high risk of developing pressure sores but there was no care plan in place to detail the action staff should take to prevent pressure sores; 1 resident was assessed as having difficulties with communication but no plan was in place to address this. The care plans in place had clear details of the action needed by staff and had all been reviewed monthly up to date. One resident commented that they were “well cared for” and other residents / relatives said that their needs were met by the home. One relative spoken with was pleased that the resident had made good progress since admission to Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 11 the home. Staff spoken with were knowledgeable about the care needs and preferences of residents. Records were seen of the input of health care professionals, such as GPs, district nurses, chiropodist, dentist and optician. Residents / relatives spoken with said that the GP was called promptly when needed and that appropriate referrals were made to other services as needed. One resident and a relative spoken with were pleased that staff accompanied residents to hospital outpatient appointments if needed. The home had a clear policy/procedure for the safe handling of medication. The medication administration records seen were correctly and fully completed. Records were seen of the ordering, receipt and disposal of medication and these were all up to date. Medication was securely stored. Residents and relatives spoken with said that staff respected the privacy and dignity of residents. One relative said that staff “speak properly” to residents and “treat them like their own family”. Residents commented that staff were “friendly”, “kind” and “patient”. During the inspection, staff were observed to knock on doors before entering and to speak to residents in an appropriate manner. Residents’ preferred names were noted in their care records. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were encouraged to exercise choice and control over their lives and were offered a range of activities so that their social, cultural and religious needs were met. EVIDENCE: A care assistant at the home had recently taken on responsibility for organising activities for residents. Brief records had been started of activities held and of who had joined in. The manager said that it was planned that more detailed records would be kept. Activities included games, bingo, and music. The activities organiser had started to plan some trips out using the local community transport service. Residents and relatives spoken with were generally pleased with the activities offered. It was commented that there should be more activities and a wider range to include more residents. There was a church service in the home every month and one resident said they enjoyed attending this. Visitors spoken with said they were always made welcome and were able to visit at any time. The home had links with a local secondary school to provide work experience placements. Some residents were able to enjoy walks into Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 13 the village to use local shops. Several of the residents spoken with had lived locally prior to admission to the home and were pleased they could stay in the area. Residents and relatives spoken with said that meals at the home were of a good standard and that residents could have a choice. Care records included an assessment of the resident’s nutritional needs. Residents and relatives were pleased that meals were home made. The menus were seen and appeared varied and balanced. The manager said that residents were consulted about the menus and staff spoken with confirmed that the menus included favourite meals chosen by residents. The lunch on the day of the inspection appeared appetising. The dining rooms were pleasant and residents could choose to eat in their own bedrooms if they wished. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There was a good system in place for responding to complaints ensuring that residents were confident their complaints would be taken seriously. Residents were safeguarded from abuse by the awareness and attitudes of staff. EVIDENCE: No complaints had been received by CSCI about the home since the last inspection. Residents and relatives spoken with said they were aware of the complaints procedure. They said they would be happy to take any concerns to the staff or the manager and they were confident that action would be taken. The staff training records seen showed that all staff had received training in safeguarding adults. Staff spoken with were aware of safeguarding adult issues and the procedures to follow. At the last inspection it was found that the home had not been complying with Regulation 37 which required them to notify CSCI of certain events, such as the death of a resident, or any incident where the police are called. Information and guidance had been provided to the manager. Although no notifications had been received by CSCI since the last inspection, the manager said this was because there had been no events to notify. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 15 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The standard of the environment in the home was good, providing residents with a comfortable, clean and pleasant place to live. EVIDENCE: Residents and relatives commented that the home was “comfortable” and “homely”. Residents and relatives spoken with were pleased with the bedrooms and all the bedrooms seen were personalised with residents’ own belongings. Some relatives commented that some communal areas of the home were in need of redecorating and refurbishing. It was observed that the décor in the ground floor lounges appeared ‘tired’ and worn. The carpets in the ground floor lounges and the main corridors on both floors appeared worn and stained. The manager said that redecoration and new carpets were planned. There was a cracked windowpane in one bedroom. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 16 The home was clean and free from offensive odours throughout. Residents and relatives spoken with were pleased with the standards of cleanliness in the home. Staff training records showed that all staff had received training in control of infection. Staff were observed to use disposable gloves and aprons when assisting with personal care. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There was a well-motivated, competent staff team to ensure residents’ needs were met. There were gaps in staff records that may put residents at risk. EVIDENCE: The staff rotas were seen and showed that there was always a qualified nurse on duty plus usually 5 care assistants for the morning shift and 4 for the afternoon shift. Night shifts were covered by a qualified nurse plus 3 care assistants. Staffing levels for some days were lower, with 4 care assistants for the morning shift and 3 for the afternoons. The manager said that this sometimes happened during holiday periods. The staffing levels were within the Residential Staffing Forum guidance. Residents and relatives spoken with said that staff were usually available when needed. Staff spoken with said that staffing levels were usually good. It was noted that there was a good level of support from ancillary staff with kitchen staff on duty to prepare lunch and tea, housekeeping staff whose duties included making beds, laundry staff, and a handyman. The staff training records were seen and training was discussed with staff. The records showed that all except 2 of the care staff had achieved NVQs in care at Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 18 level 2 or 3. This was well above the national minimum standard of 50 of care staff. The manager had completed the NVQ Level 4 Registered Manager’s Award in April 2006. Each member of staff had their own individual training file and they were responsible for keeping this up to date. The records seen were up to date and included comments from staff on the relevance and usefulness of the training they had received. In addition to the statutory training, such as fire safety and manual handling, staff had received training in other areas, such as dementia awareness, infection control, and coping with bereavement. Staff spoken with said that there was a good programme of staff training at the home and they were actively encouraged by the manager to undertake training. Staff records were examined. Since the last inspection efforts had been made to ensure all records included 2 written references. 2 records seen did not include 2 written references, photographs or a recent form of identification for the members of staff. Both records did include a Criminal records Bureau disclosure. Staff records were securely stored. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was well-managed and was run in the best interests of residents. EVIDENCE: The owner/manager of the home had achieved the NVQ Level 4 Registered Manager’s Award in April 2006. Residents and relatives spoken with said they were able to go to the manager with any concerns and were confident that appropriate action would be taken. Staff spoken with liked the hands on attitude of the manager and said she was approachable. Staff said they could go to the manager with any concerns or ideas. There was a quality assurance system in place, which included regular surveys sent to residents and relatives. Recent surveys had been about meals, laundry, and standards of cleanliness. A survey was planned about activities Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 20 offered in the home. The surveys were carried out by a nominated member of staff who then analysed the responses. There was no annual report produced from the findings of the surveys. Relatives spoken with confirmed that they had been included in the surveys. As at previous inspections, the manager confirmed that the home did not hold any personal money for residents. The home’s fees included hairdressing, toiletries and newspapers. Charges for chiropody were extra and were added to the monthly fee invoices. Residents were provided with lockable storage in their bedrooms for money and valuable possessions. Health and safety records were sampled and were well organised and up to date. The records seen included the fire logbook, accident records, maintenance and servicing records. One care assistant had been given responsibility for regularly checking the contents of the first aid boxes. Another care assistant was responsible for carrying out weekly fire alarm tests and ensuring the fire logbook was kept up to date. It was recommended that the accident reports should be stored separately in accordance with data protection legislation. It was observed during the inspection that wheelchairs were used without the footplates in place and tipped back to avoid the residents’ feet catching on the floor. This had been observed at the previous inspection and discussed with the manager as a potentially unsafe practice. At this inspection further discussion took place and the manager was advised to carry out risk assessments for residents who chose to use wheelchairs without footplates or where the use of footplates could possibly cause injury. Hollybank Nursing Home DS0000066973.V305891.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 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 3 X 3 X 3 X X 2 Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP2 Regulation 5A Requirement Timescale for action 30/09/06 2. 3. OP7 OP29 15(1) 19(1)(b) 4. OP38 13(4)(b) (c) Individual written terms and conditions must be issued to each resident. Original timescale 30/11/04 Each resident must have a care 10/09/06 plan that includes all of his or her assessed needs. A photograph and recent form of 30/09/06 identification must be obtained for every person employed at the home. Original timescale 30/11/05 A risk assessment must be 10/09/06 carried out and documented for each resident using a wheelchair without footplates. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Residents / their representatives should be involved in the planning and review of care. DS0000066973.V305891.R01.S.doc Version 5.2 Page 23 Hollybank Nursing Home 2. 3. 4. OP19 OP33 OP38 The cracked window in the identified bedroom should be replaced as soon as possible. An annual report of the quality assurance surveys should be made available to residents and their representatives. The reports of accidents to residents and staff should be stored in accordance with data protection legislation. Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Hollybank Nursing Home DS0000066973.V305891.R01.S.doc Version 5.2 Page 25 - 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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