Inspection on 19/11/07 for Hollybank Residential Home

This inspection was carried out on 19th November 2007.

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 Residential Home 22/06/09

Hollybank Residential Home 21/05/08

Hollybank Residential Home 28/11/06

Hollybank Residential Home 09/11/05

Hollybank Residential Home 28/04/05

Hollybank Residential Home 22/02/05

Hollybank Residential Home 15/06/04

Hollybank Residential Home 15/03/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hollybank Residential Home 321 Chapeltown Road Leeds West Yorkshire LS7 3LL Lead Inspector Ann Stoner Key Unannounced Inspection 19th November 2007 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 Residential Home DS0000001464.V355238.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 Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybank Residential Home Address 321 Chapeltown Road Leeds West Yorkshire LS7 3LL 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) 0113 2628655 0113 2624660 Select Choice Residential Services Limited Mrs Denise McEvoy Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 Brief Description of the Service: Hollybank is situated in the Chapel Allerton area of Leeds, close to shops and places of worship, with good public transport links to the city centre. Buses stop outside the home and there is a small car parking area for visitors at the front. The home is registered to provide care, without nursing, for sixteen people over the age of 65. Accommodation is over two floors. There are eight single bedrooms on the ground floor with other rooms on the first floor accessible by a stair lift. Two of the rooms on the first floor are shared and the remainder are single. None have en suite facilities. The communal lounge and dining areas are on the ground floor and are large, comfortable rooms. The current fees charged are from £397 and £416 per week. There are additional charges for hairdressing, newspapers and chiropody. The manager provided this information on the 19th November 2007. More up to date information about fees and copies of previous inspection reports are available at the home. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced and was carried out by one inspector who was at the home from 9.30am to 5.30pm on the 19th November 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. Survey forms were sent out to people living at the home, their relatives and health care professionals. Information from returned survey forms is reflected in this report. An AQAA (Annual Quality Assurance Assessment) was completed by the home before the visit to provide additional information. During the visit a number of documents were looked at and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager, staff and visitors. Feedback at the end of the visit was given to the manager. I would like to thank everyone who contributed to the inspection process and to the home for the hospitality throughout the day. What the service does well: There is a friendly atmosphere in the home and visitors are made to feel very welcome. Staff work well as a team and feel that they have a lot of support from the manager. In a survey form one visitor said: • “As a visitor I am always welcomed, especially by the very friendly and approachable manager.” People living at the home and their relatives were very pleased with the food. Comments in survey forms include: • “The food is very well prepared and presented. I am very impressed with the amount of baking of cakes, flans, pastries etc, which is made on the premises, even bread rolls. Fresh fruit is always on offer.” Visitors felt that they were consulted and informed about any changes affecting their relatives. Comments in surveys include: • “Always keep me informed about any issues affecting my mum’s health.” DS0000001464.V355238.R01.S.doc Version 5.2 Page 6 Hollybank Residential Home • • “They always keep me informed.” “I am always told if mum has a dressing on her leg or if she isn’t eating well.” What has improved since the last inspection? What they could do better: Overall inadequate staffing levels affect the outcomes for people living at the home. For example, in addition to their caring duties care staff have to carry out all catering and cleaning tasks in the home, which means that at times people living there are left unsupervised, with the risk of care not being given. This was identified at the last inspection but has not been addressed by the home. The manager and her deputy carry out caring tasks, which limits the time they can devote to management and supervision of the home. During this inspection the laundry was dirty, proper hygiene measures were not taken, there was stained and soiled bed linen on people’s beds, and window restrictors were not fitted on first floor windows which posed a health and safety risk to people living at the home. To address these issues the home must make sure that there are sufficient numbers of staff on duty at all times to meet the needs of the people who live there. Catering and cleaning staff must be recruited. The laundry must be clean and proper hygiene measures must be taken to stop the spread of infection. All bedding must be reviewed and senior staff must make sure that beds are made properly and that stained and soiled linen is replaced. This was identified at the last inspection and again something that the home has failed to address. Window restrictors must be fitted as a matter of urgency and until this work takes place risk assessments must be completed. Care records are poor and do not show the precise needs of people or of the care that should be given by staff. Staff rely more on verbal information passed from person to person rather than on daily records. This creates a very real risk that people’s needs will be misunderstood or overlooked. The manager must make sure that everyone living at the home has a care plan that shows all of the person’s needs and gives instructions to staff about how Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 7 the person’s care should be given taking into account their culture, beliefs, likes and dislikes. Medication was not handled, stored, given and recorded properly, which increases the risk of mistakes being made. A number of requirements and recommendations were made to make sure that medication is stored, given as prescribed and proper records made. A full list of requirements and recommendations made as a result of this visit can be found at the end of this report. 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 Residential Home DS0000001464.V355238.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 Residential Home DS0000001464.V355238.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): Standards 1, 2, 3, and 5. Standard 6 does not apply to this home. People who use the service experience adequate quality outcomes in this area. People thinking about moving into the home, and their family or friends, are given information about the home before making any decision about moving in. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The home has a statement of purpose that gives information about the home. There is also a service user guide which gives more detailed information about day-to-day life in the home. At the time of this visit the manager was in the process of updating this. She was given advice on how to make it more ‘user friendly’ by using a large font size, colour, pictures and photographs so that it could be read and understood by people living at the home. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 10 The assessment records of people admitted since the last inspection were looked at. All had a signed contract and terms and conditions and the manager had carried out a pre-admission assessment to make sure that the home could meet the person’s needs. Each assessment showed that the person being assessed was involved and included in the process, which is good practice, but there was no information about where the assessment took place and other people providing information. The assessments lacked specific detail. For example one person’s assessment said, ‘Needs staff assistance with washing, bathing and dressing’ but failed to show what the person could do for herself and the precise level of assistance she needed from staff. Another assessment said, ‘Poor short term memory’ but failed to show how this affected the person’s day-to-day life. The limited assessment information did not always trigger a care plan. For example there was no mental health care plan for people whose assessment showed that they had memory loss, and there was no continence care plans for people who were assessed as having continence needs. Because assessment information is limited and care plans are not always in place the precise level of care needed by some people may be overlooked. Surveys completed by people living at the home show that everyone receives a contract and that people felt they had enough information about the home before moving in. One person said, “I had a weeks trial and felt at ease and settled very quickly.” Comments from relative’s surveys included: • • My mother settled very quickly, much to our delight. The way the manager treated her, with compassion, made all the difference. She was offered a choice of soft furnishings in her room. They (staff) helped me with the hardest decision I have ever had to make. Two visitors spoke about being made welcome on pre-admission visits to the home. Hollybank Residential Home DS0000001464.V355238.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): Standards 7, 8, 9 and 10. People who use the service experience poor quality outcomes in this area. The over reliance on verbal information means that there is a very real risk of people’s needs being overlooked. Unsafe medication practices create the risk of errors. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: A selection of care plans was looked at and in each case the level of detail recorded was poor and did not accurately reflect the person’s needs or the care that was needed. Care plans are standardised, which was identified at the last inspection visit, and therefore care is needed to make sure the precise level of care each person needs is recorded. Sadly, this was not the case. Each person had three plans, Social Care, Personal Care and Independence. All of these were exactly the same, despite people having very different needs. One person was described as being, confused, incontinent and prone to falls. There were no care plans in place for mental health, continence or the prevention of falls. Another person had diabetes and had continence needs. There were no Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 12 plans for diabetes, nutrition or continence in place. When staff were asked how they knew when and how to deliver care to this person they said ‘You just get used to it, it is something that becomes automatic.’ Staff feel that they know about people’s needs but were unable to describe some of the specific needs of people with dementia, saying, “They have the same needs as anyone else. You just need common sense to work with people with dementia.” It is clear from staff responses in survey forms that they believe there are good communication systems in the home. One person said, “Information is always handed over to each shift as they arrive.” However, verbal information passed from one carer to another creates a very real risk of information being distorted and unless information is recorded accurately, and in detail, people’s needs may be unmet. For example, staff said that continence is promoted by assisting people to the toilet every 2 hours and by using continence products such as pads. This is not recorded in care plans. One person who has continence needs was not assisted to the toilet during the morning. When he was assisted to move at lunchtime both his chair and his clothing were wet. There were no nutritional assessments in place to identify those people who may be at risk and no accurate risk assessment to identify those people at risk of falling. One person had a large bruise around one eye, which was a result of a fall. She did not have a care plan for the prevention of falls and there was nothing in place to show any measures to prevent further falls. Staff do not make daily records in care plans, which means that the home has no evidence of the care that is given on a daily basis. There was evidence in care records of people being seen by GPs (General Practitioners) and community nursing staff. All of the people living at the home said they always receive the medical support they need. In a survey form one person said, “Any medical advice and treatment is given promptly.” Another said, “I am very well cared for.” Comments in surveys completed by relatives included: • “I think the home looks after people. I am pleased to have my mother at Hollybank.” Medication is not always managed properly. Each person has a Medication Administration Record (MAR) and a selection of these was looked at. One person had been prescribed antibiotics. The MAR showed that the home received 20 tablets, one to be taken four times a day over a five-day period, but then showed 23 entries of this medication being given. This suggests that records are not made at the time that the medication is given. The home’s pharmacist printed most of the medication on the MAR, but where the home needed to make a handwritten entry this was not always signed by the person making the entry and the amount of medication received was not always recorded. Handwritten entries were not checked and countersigned by a second person, which increases the risk of errors. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 13 Medication is stored in a locked kitchen cupboard. All cupboards in which medication is stored should be situated away from sources of heat and moisture. Therefore, the kitchen is unsuitable for storing medication. Keys to the medication cupboard are attached to other keys that are part of the master system. This is unsafe because it allows unauthorised access to the medication. There are no facilities for storing controlled medication. The home uses a Nomad system for medication, which is dispensed by a local pharmacist. A record of what the pharmacist has dispensed is on each person’s Nomad pack. One Nomad pack had Trimethoprim and Co-amilofruse that had not been dispensed into the Nomad pack by the pharmacist. The deputy manager said that this medication had been added to the Nomad by staff. This is unsafe practice and is unacceptable because it increases the risk of errors and some medication may not be suitable for removing from the manufacturers’ packaging. When ordering repeat prescriptions the home does not check or see the original prescription before it is sent to the pharmacist. This means that there is no check of what has been ordered against what has been prescribed. Screening is provided in shared rooms, but the privacy and dignity of people living at the home is compromised because a toilet door on the first floor cannot be locked. Hollybank Residential Home DS0000001464.V355238.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. People who use the service experience adequate quality outcomes in this area. Overall, people were happy with their life at the home but lack of staff awareness and inadequate staffing levels means that not everyone’s diverse, cultural and social needs are met. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: There were records in the home of regular church services and communion taking place. However, staff were unaware of how cultural needs affect people’s lifestyle, and how some of those needs could be met at the home. For example staff said that one person, originally from Jamaica had no cultural needs, but then described how this person’s family brought him a culturally appropriate meal into the home once a week. It would be good practice for the home to consult with this person and his family to discuss how his dietary and other cultural needs could be met by the home. Some people spoke about choices such as getting up in the morning and going to bed at night, but one person said that some choices such as getting up in Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 15 the morning are determined by the time that breakfast is served and when staff are available. The routines and practices in the home show that staff work in a task orientated way rather than using a person-centred approach based on the likes and dislikes of the person in every aspect of their care. During the morning of this inspection the only time that people in the lounge area had any interaction with staff was at times when care was being delivered. Most people were asleep in their chairs the remainder were watching television. During the afternoon the deputy manager arranged some group activities, but again staffing levels prevent staff from working on a oneto-one basis with people. Everyone has a social care plan but these are standardised and do not refer to people’s past or present interests. An activity record showed that bingo, quizzes, a motivation class, film shows, dominoes and cards had all taken place during the previous week. The AQAA states that people living at the home choose the activities that take place and monthly concerts are arranged. Some people living at the home said that they were bored at times but in a survey one person said, “I am very lucky, I enjoy activities and take part.” In returned survey forms relatives said: • • “Could be improved by arranging more trips out and about.” “There could be a few more stimulating activities and I am not convinced that those residents who have few, if any family members, are taken out enough in the course of a year. In addition to their caring duties care staff work in the kitchen, cleaning, cooking, serving and clearing away after meals. Although staff have training in food hygiene none have a qualification in catering. In returned surveys people living at the home were complimentary about the food. Comments include: • • • “The food is first class.” “Food very good.” “The food is excellent. Most of the baking is done on the premises. It is always well presented.” • During the inspection the food was nutritious and looked appetising. There is a choice at the lunchtime and teatime meal. Visitors were made welcome during the day and appeared to have a good relationship with staff. Hollybank Residential Home DS0000001464.V355238.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): Standards 16 and 18. People who use the service experience adequate quality outcomes in this area. Lack of staff awareness means that any suspicion or allegation of abuse may not be dealt with properly. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The home has a book for recording complaints; there are none recorded since the last inspection visit. Four people living at the home who returned survey forms said that they knew who to speak to if they had a complaint and their comments included: • • “Nothing to grumble about – very happy and always feel safe.” “Someone always notices if I have a problem.” Seven out of nine people who returned surveys said that they knew how to make a complaint. The home’s complaint procedure is displayed on the back of the lounge door along with various other posters about activities. The procedure tends to be ‘lost’ amongst the other information displayed and is not accessible to people living at the home. The format of the procedure is not suited to the needs of people living at the home, in that it is not in large print and is not easy to read. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 17 The manager said that information about making a complaint would be incorporated into the new service user guide. Staff knew that any safeguarding (abuse) issues must be reported but when asked about a specific situation they were unaware of the importance of immediate reporting and their own responsibility to report to anyone other than the manager or owner. Hollybank Residential Home DS0000001464.V355238.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): Standards 19, 24 and 26. People who use the service experience poor quality outcomes in this area. Infection control is not well managed and as a result the risk of infection in the home is increased. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: There is a serious risk of cross infection in the home. The laundry is in a cellar that can only be accessed through the kitchen, which in itself poses a problem. The laundry room was dirty. Paint on exposed brickwork was peeling off and was crumbling on the floor. There were no facilities for clinical waste other than a black bin liner that was fastened to a valve on exposed piping. This bin bag was overflowing and used latex gloves were strewn on the floor. Dirty linen, some of which was covered in faeces and some that was stained with urine was piled on the floor. There was no liquid soap for hand washing. The laundry room was also used as a storage room for cleaning materials as well as Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 19 foodstuff. There were two opened bags of potatoes near to the pile of soiled linen, and a freezer and fridge contained milk and bread. Staff felt that they had a good understanding of infection control and knew when to wear protective clothing, but were unaware of the risks associated with the home’s system of hand sluicing soiled linen. The home does not use water-soluble bags for laundering soiled items, which increases the risk of infection. Comments from relatives in survey forms suggest that they are happy with the level of cleanliness in the home and included: • • “My mother’s room is always clean, cosy with co-ordinating curtains and bed linen. Little things mean a lot.” “The cleanliness of the premises is always spotless.” All four people living at the home who completed a survey said that the home is always clean and one person said, “I really love my bedroom it is always clean and fresh.” The bed linen and pillows on some beds were stained. Some bedroom windows on the first floor had no restrictors fitted and were capable of opening wide. This is a serious health and safety risk. The manager said that this had been identified during a recent health & safety visit and was due to be addressed in 2008. Because of the risk involved to people living at the home this must be addressed as a matter of urgency and until the work is completed risk assessments must be carried out for people in these rooms. The bath on the first floor is very low and could pose health and safety issues for staff and people at the home. This was identified at the last inspection in November 2006. However, the home’s annual maintenance plan shows that the bath and floor covering in the bathroom is to be replaced. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30. People who use the service experience poor quality outcomes in this area. Staffing levels are unsafe and do not meet the needs of people living at the home. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: During a routine pre-inspection telephone call to the home it was identified that staffing levels were inappropriate and as a result a serious concerns letter was sent to the registered provider (owner). The home does not employ any domestic or catering staff. From 7am - 3pm there are two care workers on duty and 1 manager or senior staff. In addition to carrying out their caring tasks the two care workers carry out all the catering, domestic and laundry tasks in the home. The duty rota shows that on some weekends there are just two care workers on duty from 7am – 3pm, with ‘on-call’ support from the manager. From 3pm – 8pm there are only two care workers on duty, again they have to prepare, serve and clear away the evening and suppertime meal. There is one person on waking night duty who in addition to her caring duties carries out ironing duties in the cellar and one person asleep on the premises on an ‘on-call’ basis. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 21 These staffing levels are inappropriate and put people living at the home at risk of having their needs unmet. During the morning of this inspection visit one care worker was cooking and the other cleaning, which left people unsupervised in the lounge, many were sleeping in their chairs, left without any stimulation other than the television. A care worker said that people who were incontinent were assisted to the toilet every 2 hours. This did not happen and one person was wet when assisted to move from his chair at lunchtime. During the morning the only time that people had any interaction from staff was when a mid-morning drink was being served and when a care worker passed through the lounge with her cleaning materials. In a returned survey form one care worker said, “The residents always come before any domestic tasks.” The recruitment and selection file of a person recently appointed was sampled. All of the necessary pre-employment checks had taken place. New staff complete an induction programme based on the Skills for Care common induction standards. In survey forms returned by staff comments included: • • • “Inductions are very thorough and management are always there for support.” “We are always given information, updates and choices of any new training and courses to bring us up to date with any changes.” “I have learnt so much more since working at Hollybank. I am always encouraged to do any courses that come up.” Over 50 of the staff team have an NVQ (National Vocational Qualification) at level 2 in care. The AQAA (Annual Quality Assurance Assessment) shows that in the last 12 months staff have had training in first aid, medication, COSHH (Control of Substances Hazardous to Health), infection control, abuse, diabetes and incontinence. Because there is no overall plan showing what training each person has completed or when mandatory training updates are due the only way training can be monitored is by trawling through each person’s staff file. This can be time consuming and training updates may become overdue. This inspection report identifies shortfalls in the way that the home manages infection control, abuse and continence. Staff have had training in these areas in the last 12 months, which suggests that the quality of the training is questionable or that staff are not putting theory into everyday working practice. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35 and 38. People who use the service experience poor quality outcomes in this area. Staffing levels affect the amount of time the management team are able to devote to the running of the home. This means that proper records are not always kept and health and safety risks to people are not always identified. This has the potential to place people at risk. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The manager has many years experienced working with older people and has completed the Registered Manager’s award. The AQAA states that a deputy manager has been promoted enabling the manager and deputy to share the administration work. However, with the current staffing levels the manager and deputy both carry out care tasks, which, ultimately affects the time they Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 23 have to devote to management of the home. Many of the issues identified in this report reflect on the poor management of the home. On a positive note in returned surveys staff feel that they have good support. Comments include: • • • “My manager is very helpful and encourages everyone to work together as a team.” “All work as a team.” “The management are always there for support or if we need to discuss any issues relating to our work.” The manager said that the owner sends out quality assurance surveys on an annual basis to people living at the home, their relatives and other professionals such as GPs. She said that when these are returned they are analysed by the owner, who then, together with the manager, formulates an action plan. There was no evidence of this in the home. The owner does not carry out Regulation 26 visits on a monthly basis as required by the Care Homes Regulations 2001. Staff meetings take place and minutes of these were seen. The manager said that no monies are held on behalf of people living at the home. Weekly fire tests are carried out and fire drills are held regularly. The deputy manager carries out weekly health and safety checks, however the lack of restrictors on the first floor windows was not identified during these checks, nor were poor hygiene measures in the laundry. Accident and incident records are not analysed each month, therefore patterns or trends cannot be identified. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 24 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 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 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 1 X X X X 2 X 1 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (1) Requirement Everyone living at the home must have a care plan that clearly shows what the person’s needs are in all aspects of their life and how staff should deliver the care needed. This will make sure that care is given in a consistent way according to the person’s beliefs, likes and dislikes. It will also prevent needs being overlooked. Medication must be given as prescribed and a record must be made at the time that it is given. Medication must only be administered from the containers supplied by the pharmacy. This will reduce the risk of mistakes. Medication must not be stored in the kitchen. This will make sure medication is stored away from moisture and heat. All staff must be aware of the DS0000001464.V355238.R01.S.doc Timescale for action 28/02/08 2. OP9 13 (2) 15/12/07 3. OP18 13 (6) 15/12/07 Page 26 Hollybank Residential Home Version 5.2 local safeguarding procedures and how and when to report any safeguarding suspicions or allegations. This will make sure that staff respond properly if, and when, the need arises. The laundry room must be clean at all times. A clinical waste bin and liquid soap must be provided in the laundry. The practice of hand sluicing must cease. Water-soluble bags must be used for laundering soiled linen. Food and cleaning materials must not be stored in the laundry. This will reduce the spread of infection in the home. Window restrictors must be fitted 01/01/08 to all first floor windows. This will make sure that people are safe. A full review of bedding must take place. Stained pillows must be replaced and stained bed linen must not be used. This will make sure that people have clean and comfortable beds. This was identified at the previous inspection and the timescale of 5/3/07 is unmet. There must be sufficient numbers of staff on duty at all times. 4. OP19 OP26 13 (3) 15/12/07 5. OP19 OP38 13 (4) (a) 6. OP24 16 (c) 15/12/07 7. OP27 18 (1) (a) 01/01/08 Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 27 Care staff must not be taken away from caring duties to carry out domestic tasks. There must be sufficient ancillary staff to support the care staff. This will make sure that people’s needs are met. This was identified at the previous inspection and the timescale of 2/4/07 is unmet. The registered provider must carry unannounced Regulation 26 visits to the home. A copy of these reports must be made available to CSCI. This will makes sure that the home complies with the Care Homes Regulations 2001. 8. RQN 26 15/12/07 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 OP3 Good Practice Recommendations Pre-admission assessments should be clear about people’s needs and the precise level of care needed. This will make sure that the home can meet the person’s needs and that staff have enough information to provide the care required. Staff should make a daily record in every care plan. This will make sure that the home can show how and when care has been delivered. The home should carry out nutritional and falls risk assessments on admission and later as necessary. This will make sure that people who are at risk are accurately identified and action is planned to reduce risk. Staff should sign any handwritten entries on Medication Administration Records (MAR) and record the amount of DS0000001464.V355238.R01.S.doc Version 5.2 Page 28 2. 3. OP7 OP7 4. OP9 Hollybank Residential Home medication received. The entry should be checked and countersigned by a second person. The home should check and sign all repeat prescriptions before they are sent to the pharmacist. This will reduce the risk of errors. Keys to the medication cupboard should be separate from other keys in the home. This will prevent unauthorised access to medication. The home should consult with people living at the home, and where necessary their relatives, to identify any cultural needs. The home should then look at ways to meet any identified needs. Staff should be made aware of the different ways that culture affects people’s lives. This will make sure that people’s culture and beliefs are respected and met. Activities should be provided that are based on people’s past and present interests. This will make sure that people have the opportunity to take part in activities that interest and stimulate them. The home should move from a ‘task orientated’ to a ‘person centred’ approach when delivering care. This will make sure that care is delivered in a way that meets each person’s choice, likes and dislikes. There should be a training matrix and an annual training plan in place that shows the training each person has completed, when mandatory training updates are needed, and what training is planned. This will make sure that mandatory training updates are not overlooked. The home should keep evidence of when quality assurance surveys are distributed, the results of the surveys and any action taken as a result of the returned surveys. People returning surveys should be made aware of the results of the survey and any subsequent action plan. This will make sure that the home is listening and responding to the views of everyone concerned and is improving the service in view of any feedback. It will also keep people informed and assured that their views are Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 29 5. OP12 6. OP12 7. OP14 8. OP30 9. OP33 9. OP38 taken seriously. The manager should analyse all accidents and incidents in the home on a monthly basis. This will make sure that any patterns or trends are identified. Hollybank Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Residential Home DS0000001464.V355238.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!