Inspection on 08/02/06 for Hollybank Nursing Home

This inspection was carried out on 8th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 08/08/06

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 16/02/2010.

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 February 2006 10:30 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.V282609.R01.S.doc Version 5.1 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.V282609.R01.S.doc Version 5.1 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 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.V282609.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/09/05 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. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a period of 5½ hours. There were 27 residents accommodated in the home on the day of the inspection, including 5 residents assessed as needing nursing care. Residents, visitors and staff were spoken with during the inspection. The care records of three residents were examined, plus staff records, medication records, and health and safety records. A tour of the building was carried out. The owner/manager was available and very helpful throughout the inspection. Two complaints about Hollybank had been received by CSCI and had been investigated by the home and by CSCI. Requirements made regarding some elements of the complaints were followed up at this inspection. It was found that all except one of the requirements had been met. This requirement was about the décor of a specific bedroom and has been carried forward in this report. What the service does well: What has improved since the last inspection? What they could do better: Residents did not have individual statements of terms and conditions, and the copy of the terms and conditions seen did not include all the required information. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 6 Staff files needed further work to include all the required information for the protection of residents. One staff file did not include a Criminal Records Bureau disclosure and an Immediate Requirement was made for the owner/ manager to address this urgently. The home had not been informing CSCI of various occurrences, as required under Regulation 37 of the Care Standards Act, (such as certain accidents to residents). This was necessary to safeguard residents and staff. 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.V282609.R01.S.doc Version 5.1 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.V282609.R01.S.doc Version 5.1 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): 1 and 2 There were improvements in the information provided for residents, although residents did not have individual statements of terms and conditions. EVIDENCE: At the last inspection the Statement of Purpose was in draft form as it had been reviewed and updated. At this inspection the Statement of Purpose had been completed. The statement of terms and conditions for residents was seen. This included most of the information required, except for specifying the room to be occupied by the resident, and a breakdown of the fees payable, including the Registered Nursing Care Contribution where applicable. Residents had not been provided with individual statements of terms and conditions. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 9 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, 9 and 10 Residents’ needs appeared to be well met, including respecting privacy and dignity. The systems in place for the handling of medication generally ensured residents’ safety. EVIDENCE: The care records of three residents were examined. All the records had individual care plans which included all the assessed needs of residents and had been reviewed monthly. The home had introduced separate records of the visits / input of other healthcare professionals, such as GP and District Nurse, as recommended at the last inspection. There was evidence in the care records of respecting the dignity and privacy of residents, for example, a note of the preferred name, details of residents’ preferences regarding their daily routines, and reference to respecting privacy and dignity included in care plans. Residents spoken with gave examples of how the staff ensured their privacy and dignity, such as knocking on doors before entering, ensuring doors are closed during personal care, respecting choices such as where to eat meals and not wanting to join in activities. Staff were observed to knock on doors before entering. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 10 Medication in the home was securely stored and was administered by the registered nurses. One resident had chosen to self-medicate and used a locked drawer to store medication in the bedroom. The Medication Administration Records, (MARs), were seen. These were generally correctly and fully completed and all had a photograph of the resident. There were some handwritten entries on MARs which were not signed by the nurse who had written them or countersigned by another nurse to ensure they were correct. There were also handwritten entries which did not include all the information required. The records of receipt and disposal of medication were seen and were satisfactory. The home’s policy for the safe handling and administration of medication was seen and included all the required information. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 11 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): 14 Residents were encouraged to exercise choice and control over their lives. EVIDENCE: The bedrooms seen were mostly well personalised with residents own possessions and photographs. Residents spoken with were pleased that they could bring personal items into the home, including furniture. Residents spoken with said they were able to exercise choice, such as meals, activities, and daily routines. Staff spoken with were knowledgeable about the personal preferences of residents. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 12 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 Generally, residents were protected by the home’s policies and procedures and by staff attitudes and awareness. However, a lack of knowledge of legal requirements potentially affected residents’ safety. EVIDENCE: Two complaints about the home had been received by CSCI in 2005. The complaints each involved the care of specific residents, and one complaint included elements about the organisation of the home. Requirements had been made of the home to address the elements of the complaints that had been upheld. It was found at this inspection that all except one of the requirements had been met. This requirement was about the décor of a specific bedroom and has been carried forward in this report. The two complaints were investigated by the home and by CSCI. The home responded appropriately to the complaints, although not within the proper timescales. The home’s policy and procedures for the protection of vulnerable adults were seen and were satisfactory. Staff training records were seen and all staff had received adult protection awareness training. Staff spoken with were clear on the action to take if they suspected any abuse of residents. The owner/ manager of the home was not fully aware of the requirements of Regulation 37 of the Care Standards Act to notify CSCI of various significant events in the home, including reports of suspected abuse of residents and any events which adversely affect the health and welfare of residents. This was discussed during the inspection and a requirement has been made in this report, (see Standard 38). Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 13 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 Generally, the home was clean and well maintained, providing a pleasant environment for residents. EVIDENCE: A tour of the home was undertaken, including the lounges, dining rooms and most of the bedrooms. The furnishings and décor appeared of good quality and were domestic in character. There was a requirement following a complaint in 2005 that all areas of the home must be kept reasonably decorated. Although some redecoration had taken place, the bedroom identified as part of the complaint had not been redecorated. The manager said this room would be decorated as soon as possible. There was a requirement made at the last inspection that residents receiving nursing care must be provided with beds appropriate to their assessed needs. New beds had been provided to meet this requirement. It was noted at the last inspection that several doors were propped or wedged open, creating a potential fire hazard. At this inspection, no doors were observed to be propped or wedged open. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 14 Residents spoken with were pleased with the environment of the home, commenting that it was “homely”, “comfortable” and “always clean”. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 15 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): 28, 29 and 30 There was a good programme of staff training, ensuring that staff were well motivated and competent. Although staff records had generally improved since the last inspection, there were essential items missing which had a bearing on the safety of residents. EVIDENCE: The staff training records were seen and training was discussed with staff. The records were kept as individual files with each member of staff responsible for keeping their own file up to date. Several files were seen and were up to date. Staff were encouraged to comment in their files on the training received and its usefulness and relevance to their job role. In addition to the standard training, (such as fire safety, moving and handling, first aid), there was evidence of other training such as dementia awareness and coping with bereavement. One member of staff had been allocated the responsibility for ensuring training files were kept up to date and for organising the training programme. There was a training programme in place for the year with a planner to complete as training was undertaken. Staff spoken with said that training was a high priority at the home and that they were actively encouraged by the owner/manager to undertake training. All except two of the care staff at the home had achieved or were working towards NVQs in care. The staff files were seen and were better organised and more securely kept than at the previous inspection. It was a requirement at the last inspection Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 16 that staff records must include Criminal Record Bureau, (CRB), disclosures, two written references and a photograph and recent form of identification. The records seen included CRB disclosures and two references, except for one file without a CRB disclosure. This was the same member of staff identified at the last inspection as working unsupervised without a CRB disclosure. An Immediate Requirement was made at this inspection requiring the owner/manager to take urgent action to address the situation. None of the files seen included a photograph or recent form of identification and this requirement has been carried forward in this report. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 17 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): 35 and 38 Generally, the work practices and systems at the home promoted and protected the health and safety of residents and staff. However, there were omissions identified which compromised health and safety. EVIDENCE: The owner/manager said that the home did not hold any personal money for residents. The home’s fees included items such as toiletries, newspapers and hairdressing. Chiropody charges were extra and were added to monthly fees invoices. Residents or their representatives dealt with their personal money. Residents and a visitor spoken with confirmed that the home did not hold any personal money. Health and safety records were seen, such as the fire log book, accident records, maintenance and servicing records. All the records seen were well organised and up to date. During the inspection it was observed that staff used a wheelchair without the footplates attached to transport a resident and Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 18 had to tip the wheelchair on the back wheels to avoid catching the resident’s feet on the floor. This was an unsafe practice and was discussed with the owner/manager. The requirements of regulation 37 of the Care Standard Act were discussed with the owner/manager as the home had not been notifying CSCI of certain significant events, (such as accidents where a resident was admitted to hospital). Standard 33 was not assessed at this inspection but a requirement made at the last inspection was followed up. This was to provide a report of the quality assurance audits to residents. The requirement had not been met and has been carried forward in this report. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5A Requirement Individual written terms and conditions must be issued to each resident. Original timescale 30/11/04 All areas of the home must be kept reasonably decorated. Criminal Record Bureau disclosures must be obtained for every person employed at the home. Original timescale 30/09/05 A photograph and recent form of identification must be obtained for every person employed at the home. Original timescale 30/11/05 A report of the quality assurance audits must be made available to residents. Original timescale 31/12/05 The registered person must ensure that wheelchairs are used correctly and safely. The registered person must inform CSCI without delay of any of the occurrences listed under Regulation 37. Timescale for action 31/03/06 2. 3. OP19 OP29 23(2)(d) 19(1)(b) 31/03/06 01/03/06 4. OP29 19(1)(b) 31/03/06 5. OP33 24(2) 31/03/06 6. 7. OP38 OP38 13(4)(b) 37 31/03/06 31/03/06 Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP7 OP9 Good Practice Recommendations The views of residents about the home should be included in the Service User Guide. There should be a system of care reviews for residents who are self-funding and who do not have the support of a care manager, social worker or Primary Care Trust nurse. Hand written entries on Medication Administration Records should be signed by the nurse writing them and counter signed by another nurse to ensure the entry is correct. Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hollybank Nursing Home DS0000066973.V282609.R01.S.doc Version 5.1 Page 23 - 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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