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Inspection on 21/05/08 for Hollybank Residential Home

Also see our care home review for Hollybank Residential Home for more information

This inspection was carried out on 21st May 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

There have been improvements in the standard of record keeping and administration of medication. The manager has made sure that good contacts with other healthcare professional are made and maintained. This has led to medication reviews being done and changes to people`s treatment where necessary. This is good practice and means that people are getting the medication that is appropriate for their medical condition. Refurbishment of the home has continued and bedding replaced meaning that bedrooms are much more inviting and personalised. The laundry is clean and tidy and a cleaner has been appointed. This means that the risk of cross infection has been reduced and care staff are able to give more priority to looking after the people living at the home. There is a great deal of training available for all staff meaning that they are more confident and knowledgeable about their role. A great deal of hard work has been done to improve the standard of recording in records and to move more clearly towards person centred care. Overall, records we saw included some good specific detail about care and the support staff needed to provide. This means that staff have the information they need to look after people properly.

What the care home could do better:

Although there have been improvements to medication practices these improvements are not consistently maintained. This puts people at risk of not receiving their medication as prescribed. The medication policy needs to be reviewed and updated. The current policy does not provide enough informationfor staff on current legislation and guidance to make sure that safe practices are followed. The work that is already underway at the home to develop person centred care and informative care plans should continue. This is to make sure that people are cared for as they wish to be and that staff have enough information to look after them properly. The manager must make sure that staff working at the home have safeguarding training to make sure that they are fully aware of their responsibilities to keep vulnerable people safe. The manager should keep the staffing levels under review; particularly at night to make sure that there are enough staff to look after people properly. A full list of requirements and recommendations made as a result of this visit can be found at the end of this report.

CARE HOMES FOR OLDER PEOPLE Hollybank Residential Home 321 Chapeltown Road Leeds West Yorkshire LS7 3LL Lead Inspector Catherine Paling Key Unannounced Inspection 21st May 2008 09:40 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.V364883.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.V364883.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 denisemcevoy@hotmail.co.uk 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.V364883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th November 2007 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. There are no en suite facilities although application has been made by the provider to register two new en-suite bedrooms, on the first floor. The communal lounge and dining areas are on the ground floor with communal sanitary facilities provided throughout the home. The current fees charged range from £409.26 to £442 per week. There are additional charges for hairdressing, newspapers and chiropody. The manager provided this information at the inspection of May 2008. More up to date information about fees and copies of previous inspection reports are available at the home. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit by two inspectors who were at the home between 09:40 and 17:50 on 21st May 2008. The pharmacy inspector did an unannounced follow-up visit on the 2nd June 2008 and her comments are included in this report. 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 who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. The manager of the home had been asked to complete an Annual Quality Assurance Assessment (AQAA) as part of the inspection process to provide additional information. This was returned after the visit but not in time for information to be included in the report. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. Survey forms were sent out to the home before the inspection providing the opportunity for people to comment on the service, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. The home was in the process of conducting their own survey of their service as part of their quality assurance process. Information in completed surveys has been used as part of this inspection. Some of the comments received have been included in the report. What the service does well: There is a friendly and homely atmosphere at the home. Visitors are made very welcome and people can spend their time how they wish. There was enough information for people before they moved into the home and admission is managed very well. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 6 People said: • ‘very accommodating’ • ‘great reception’ • ‘go to bed when you like, get up when you like’ • ‘I get up early, I like to do that’ • ‘plenty of other people to chat to’ • ‘play cards or sit in the garden’ • ‘I am very happy’ • ‘staff are all very nice and respectful’. The manager provides stability at the home and people have confidence in her. Staff also feel well supported by her and are very knowledgeable about the people they care for. What has improved since the last inspection? What they could do better: Although there have been improvements to medication practices these improvements are not consistently maintained. This puts people at risk of not receiving their medication as prescribed. The medication policy needs to be reviewed and updated. The current policy does not provide enough information Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 7 for staff on current legislation and guidance to make sure that safe practices are followed. The work that is already underway at the home to develop person centred care and informative care plans should continue. This is to make sure that people are cared for as they wish to be and that staff have enough information to look after them properly. The manager must make sure that staff working at the home have safeguarding training to make sure that they are fully aware of their responsibilities to keep vulnerable people safe. The manager should keep the staffing levels under review; particularly at night to make sure that there are enough staff to look after people properly. 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.V364883.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.V364883.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): 1 and 3. (Standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. The home makes sure that they have information about people’s needs before they are admitted to the home. The written information available to people and their families gives them the information they need to decide if they want to move into the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: There is information for people planning to move into the home in the form of a statement of purpose and service user guide. The manager has recently reviewed these documents and the format is suitable for the current client group. The manager said that it could be reproduced in larger print if this was needed. People spoken with said that had ‘all the information they needed’ about the home. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 10 One person who had been admitted very recently to the home spoke about the manager coming to see him in hospital and being asked ‘lots of questions’ about what support and help he needed. The manager had signed the record of this assessment as well as the person involved. It was detailed and identified the strengths of the individual as well as what support was needed from staff. A record was also made of where the assessment took place, who was involved in the process and included a decision of whether the manager felt needs could be met at the home. Information was also included from the local authority assessment in summary form. This summary gave staff easy access to clear background information about the person and the reasons why the decision had been made to come into care. The manager also makes sure that she gets information from other healthcare professionals if necessary. In the case of one recently admitted person she had arranged to meet with the district nurse to get clarification about some of his needs. Everyone is offered a trial visit to the home before making a decision to move in and a record is made of this and whether people took advantage of this or not. Another person had been at the home for about three months and was very satisfied with his care and how he had been helped to settle in. One person whose daughter was visiting said that the home was ‘very accommodating’ and that they had a ‘great reception’ after moving in. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. Care plans have improved meaning that staff have the information they need to look after people properly. The improvements made in the standards of record keeping and the administration of medication are not consistently maintained and this puts people at risk of not receiving their medication as prescribed. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was evident that the manager and her staff are working hard to improve the care records to make sure that staff have clear and detailed information about how to look after people properly. Care plans provided good personal detail about people but needed more specific information about their abilities and precisely what support is needed Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 12 form staff. For example, one care plan for personal care stated ‘shaves himself every day…has one shower per week and he needs full assistance from staff but is able to wash his front, arms and legs’. So that staff know how to look after this person properly ‘full assistance’ should be explained. For example, is it to make sure that he is safe and doesn’t fall or does he need help washing his back and legs? In another care plan it was noted that another person needed ‘prompting’ regarding personal care with no information on how staff should do this. The addition of a little more specific detail would enhance the work already done on the care plans. Care should be taken to date and sign information and to make sure that there is clear information wherever a person needs staff support. Falls risk assessments and nutritional risk assessments were being completed for people. In some cases where risk had been identified there was a plan of management. In other cases risk assessment had been done, although not dated, but there was no management plan. People are weighed regularly and action taken if there is significant weight loss. One person had lost weight over a month and their diet and fluid intake were being monitored with extra snacks and food supplement drinks being given. Advice was also being sought from the dietician and GP (General Practitioner). There were records of the involvement of other healthcare professionals and people said that the staff were ‘always very prompt in getting the doctor if needed’. Staff treat people with respect and kindness. Staff knocked on doors and waited for an answer before entering and then asked if it was convenient. One person was confused about where they were and staff settled her and reassured her well, with minimal intervention. Some people and their relatives said that they had been through care plans with staff and had been asked questions by staff about the care they needed and the support they wanted. Daily records are made but are only completed once a day. There should be a minimum of twice daily recording to make sure that there is a clear record of how a person is during the day and during the night. Improvements have been made to the standard of record keeping and administration. There are no gaps on the charts and a check on medication administered matched the quantity remaining. However these improvements Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 13 are not consistently maintained. This puts people at risk of not receiving their medication as prescribed. The medication policy needs to be reviewed and updated. The current policy does not provide enough information for staff on current legislation and guidance to make sure that safe practices are followed. The current and previous month’s Medication Administration Records (MAR) were looked at. There is now a list of staff authorised to administer medicines. This means it is possible to identify who was involved in administration if a problem or error occurred. There are now names and photographs of people attached to the dividers between the MAR sheets. It is important to have names and photographs to reduce the risk of medication being given to the wrong person. The standard of accurate record keeping has improved. However one person prescribed Betamethasone cream had no MAR entry and therefore no records of administration although staff confirmed it was being applied. To demonstrate that people are getting the medication as prescribed the MAR chart should record each administration. One MAR chart for eye drops prescribed as one drop at night had records of administration for twice daily. However the chart from the previous month had records of administration matching the dose printed on the MAR of one drop at night. Staff must follow a robust system of checking the dose on the printed label and the MAR chart before administration. This is to make sure that medication is given correctly. The quantity of medication supplied and carried over from one monthly cycle to another is not recorded on the new MAR. This means it is difficult to have a complete record of medication within the home and to check if medication is being administered correctly. The date of opening of medicines with limited use once opened such as eye drops is not recorded. This means there is a risk that the medication may be used beyond the date recommended by the manufacturer and may not be safe to administer. There is now a controlled drugs cabinet but no controlled drugs register. There are currently no controlled drugs in the home. However the manager was advised that a record must be made of the receipt, administration and return of controlled drugs. This is to make sure that these medicines can be accounted for. The manager has developed a form to record changes to medication or new medicines started, which is kept with the MAR charts. This is an example of good practice as it provides staff with up to date information on a person’s Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 14 medical treatment for them to check against before administering. This helps to make sure people are getting the medication as prescribed. The manager has made sure that good contacts with other healthcare professional are made and maintained. This has led to medication reviews being done and changes to people’s treatment where necessary. This is good practice and means that people are getting the medication that is appropriate for their medical condition. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 15 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. People’s choices are respected and contact with family and friends is encouraged. A good and varied diet is provided taking peoples’ likes and dislikes into account. We have made this judgement using available evidence including a visit to this service. EVIDENCE: People said they had choice about how they spent their time: • ‘go to bed when you like, get up when you like’ • ‘I get up early, I like to do that’ • ‘plenty of other people to chat to’ • ‘play cards or sit in the garden’ One person’s records gave good information about how he liked to spend his time. He enjoyed the music and movement sessions but is a ‘very private Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 16 man’ and goes back to his room after joining in the classes. On the day of the visit we saw that this was how he spent his time. We saw information in care plans about people’s social interests. On the day of the visit there was a music and movement session, which was clearly enjoyed by the majority of people, with many of them joining in and others watching. There was a pleasant relaxed atmosphere with two students from the local college spending their shift with people in the lounge chatting to individuals and encouraging a range of activities including hand massage and knitting. It was difficult to judge how effective the day-to-day social stimulation for people is without the work placement students as the permanent staff were busy throughout the day with other tasks. There is a limited activities programme that includes card games, dominoes, bingo and music and movement. The monthly church service and hairdresser’s visits were included on this programme. Visitors are made very welcome at the home. We saw staff offering drinks to visitors and one relative said that she had been offered a meal. She has sampled the food and said it was ‘very good’. People said that they were asked about their likes and dislikes and could ‘ask for what they want’. We saw the lunchtime meal and people were given choice and encouraged to eat in a respectful way. One person said that he was ‘very satisfied’ with the food and the portion sizes and had ‘asked them for a little less’. Support was given where it was needed in a discreet manner. There are no planned menus and a record is kept in a daily diary of what has been served. People were asked what they would like on the menu at residents meetings and the cook has had training in nutrition and diabetes. She has also completed a four-day food hygiene course. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate quality outcomes in this area. A complaints procedure is made available and people feel that concerns are taken seriously. Staff must have safeguarding training to make sure that any safeguarding issues are dealt with properly. People feel safe at the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in the home and is made available to everyone when they move into the home. One person said that although the manager had not gone through the procedure he did know where to find it. People were clear that if they had any concerns they would talk to the manager or another senior member of staff. One relative said that she had information about how to complain and that if she had any issues she would phone the manager. A record is kept of any complaints received in a complaints book. It was suggested to the manager that she should review the way complaints are logged to make sure confidentiality is respected and maintained. The manager has a strong presence at the home and people feel confident to talk to her about any issues. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 18 There are safeguarding procedures in place at the home and staff spoken with said that they would not hesitate to report any abusive practice. One member of staff who was spoken with said that she had had training in the past and spoke of new safeguarding training that was being planned. There has been a recent safeguarding issue at the home, which was fully investigated by the local authority safeguarding team and no evidence was found for the allegations made. Following this, the safeguarding team felt that staff at the home needed training in safeguarding processes and procedures. They are working with the manager to provide this training at the home. People living at the home said that they felt safe: ‘staff are all very nice and respectful’. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. Overall, people live in a comfortable and safe environment. We have made this judgement using available evidence including a visit to this service. EVIDENCE: All areas of the home used by people living at the home were visited during the inspection and were found clean and fresh smelling. Generally bedrooms are comfortable and suitably furnished and there is an ongoing programme of refurbishment and redecoration in place. Window restrictors have been fitted to first floor windows. The shared rooms are not fitted with privacy screening although mobile screens are provided. There are no en suite facilities. There are communal assisted toilets, bathrooms and a shower available. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 20 New bedding has been provided and rooms are inviting with matching sets of bedding. One man particularly liked the choice of bedding, saying: ‘The bedding is manly for men, not all flouncey like women’s’ Following the inspection of November 2008 an environmental health inspection was carried out. The manager made the report available and issues raised have been addressed. The laundry was clean and tidy with hand washing facilities provided for staff. Water-soluble bags are provided for soiled linen. Most staff have completed a distance-learning course in the control of infection and new staff are to be enrolled on the course shortly. The member of staff responsible for managing the kitchen was clear about hygiene practices required in this area. Alterations at the home to provide two additional rooms, both with en-suite facilities, were complete and the provider is waiting for these two rooms to be registered for use. There are further plans in the early stages to build an extension to the home to add another two rooms. The current communal space will need to be reviewed, as part of this process to make sure that there is enough. The dining room is small and somewhat cramped at mealtimes. Staff also use this area for updating records. The lounge is reasonably spacious but also serves as a thoroughfare to access some bedrooms. This restricts the options for the layout of this room. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. Overall there were enough staff to look after people properly. People are protected by good recruitment practices. We have made this judgement using available evidence including a visit to this service. EVIDENCE: There is a core group of staff, including the manager, and this provides stability and continuity for people living at the home. Students regularly work at the home from one of the local colleges on work placement. On the day of the visit there were two students working in addition to the regular staff at the home. These two people had clearly been an asset to the home and complimented the care staff. One said: ‘I have loved it, it has made me think I’d like to work with older people’ It was noted that while the students worked well at occupying people during the day and spent time with them the regular care staff were very well occupied doing other things, for example cleaning/housekeeping duties, cooking and administration. This made it hard to form an opinion whether there would be enough staff if the students had not been there. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 22 People living at the home felt that there were enough staff. People praised the staff on duty on the day of the visit and said: • ‘always enough staff’ • ‘always help available. Plenty of staff around’ • ‘answer buzzes straight away’ • ‘mostly enough staff, occasionally there is staff sickness’ People were aware of new staff employed recently and there was a new member of staff on duty. She already has NVQ and appeared to be confident and capable in her role at the home. There is a great deal of training being provided for staff and they are keen to learn. One carer said that completing a National Vocational Qualification (NVQ) had made her feel more confident in the way she cared for people. Records of training are kept in individual files and the manager reviews these files regularly to see when training updates are due for care staff. The benefits were discussed of developing a matrix of training for easy access to this information. A copy of the annual training plan was provided. The manager does carry out formal staff supervision but there is no common format for this and records are kept of the date and time in a book. There are no individual records of supervision. The night shift is covered by one waking staff who is supported by a second carer who ‘sleeps-in’ and helps for the first and last hour of the shift. This arrangement must be kept under review as the needs of people living at the home change. Once additional beds are registered then two waking staff should be provided as a minimum. The recruitment files of recently employed staff were looked at and all the required checks are carried out before staff start work at the home. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. The manager provides stability at the home to make sure that the home is run in the best interests of the people living there. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager has many years experience working with older people and has completed the Registered Manager’s award. She provides stability and continuity at the home for staff and the people living there. We spoke to one person who had lived at the home for about three months who was full of praise for the manager saying ‘things always move when Denise is here’. He told us that they have meetings with her and feel involved Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 24 in the running of the home. At a recent meeting he told us that people had asked to have mugs for their drinks rather than cups and ‘it was sorted’. Notes are kept of residents meetings and the most recent one had been held on 20th May 2008. The sorts of topics discussed included food, activities and the ongoing refurbishment of the home. People had asked for trips out to local places of interest and plans were underway to accommodate this. The manager also meets with staff regularly with the most recent meeting 6th May 2008. Notes of this meeting included such topics as record keeping and care planning, training, planned fire drills, cleaning and the laundry system. Key workers meet with the manger on a monthly basis to discuss any issues and the needs of individuals living at the home. The provider is required to visit the home on a monthly basis and produce reports of those visits under Regulation 26. The reports were available for inspection. The provider visits regularly and also works some shifts at the home. People spoke well of him with one person referring to him as a ‘good fellah’. We saw records of accidents that have happened at the home and the manager does a monthly review of these to identify any trends or contributing factors. People and other interested parties have been surveyed annually since 2005. Information in recently returned surveys was made available to us as part of this visit. People said: • ‘could not be better’ • ‘residents clean, well taken care of’ • ‘parking can be a problem’ • ‘no reason to complain’ • ‘no comment – 10 out of 10’ • ‘very, very good’ • ‘I am very happy’ • ‘very helpful and approachable’ Two surveys from district nurses made ‘good’ or ‘excellent’ responses. Surveys have only recently been returned and the manager plans to audit the results and should then make these available to all. There is a policy of not handling people’s money and if any purchases are necessary on behalf of people living at the home the amount is added to monthly invoices. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement Medication must be given as prescribed and a record must be made at the time that it is given. This will make sure that people receive their medications correctly and the treatment of their medical condition is not affected. Timescale for action 01/09/08 2 OP18 13 (6) A system for the safe handling of medication with limited use once opened must be in place. This makes sure that medicines are safe to administer. All staff must have safeguarding 01/10/08 training so that they are be aware of the 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. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 27 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 The manager and her staff should continue the work they have started to improve the information held within care records. 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. The medicine policy needs to be updated in line with current guidance so that staff understand how to handle and administer medicines safely. A system should be in place to record medication carried over from the previous month. This helps to confirm that medication is being given as prescribed and when checking stock levels. 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 continue to develop 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. The manager should keep the staffing numbers and skill mix under review for both the day and night shifts. This is to make sure that there are enough staff to care for people properly. The manager should develop a training matrix to use with the annual training plan to show the training each person has completed. This will make sure that mandatory training updates are not overlooked and that all staff have had the training they need to properly care for people. Hollybank Residential Home DS0000001464.V364883.R01.S.doc Version 5.2 Page 28 2 OP9 3 OP12 4 OP14 5 OP27 6 OP30 7 OP33 8 OP38 The home should make the results of the annual survey available to all interested parties together with any actions planned as a result of the responses received. This means that people will know 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 taken seriously. The manager should continue to 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.V364883.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V364883.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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