CARE HOMES FOR OLDER PEOPLE
Hollybank Residential Home 321 Chapeltown Road Leeds West Yorkshire LS7 3LL Lead Inspector
Kathleen Firth Unannounced Thursday 28 April 2005, 10.00 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 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 X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 262 8655 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 X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 15 June 2004 Brief Description of the Service: Hollybank is situated in the Chapel Allerton area of Leeds with good public transport links to the city centre. The buses stop outside the home and there is also parking available for visitors to the home. The home is registered to provide care for sixteen older people over two floors. There are eight single bedrooms on the ground floor with other rooms on the first floor accessible via a stair lift. Two of the rooms are shared the remainder been single and none have en suite facilities. The communal lounge and dining areas are on the ground floor and are large, comfortable rooms. Nursing care is not provided by the home’s staff but they are able to access the District nursing services in the area. GPs and other healthcare practitioners visit the home when they are required. The home aims to provide a secure, relaxed and homely environment with principals of care focused on the individual needs of residents. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over four hours by one inspector on Thursday April 28th, 2005. The inspector toured the building, spoke with residents, staff, management and visitors, examined residents’ records including care plans, menus, staff rosters and the Service User Guide. Staff, residents and visitors were very helpful throughout the inspection process and were happy to join in the inspection process. Ten residents and five members of staff were spoken to along with the two relatives present on the day. The manager of the home was not present but the inspector had several telephone conversations with her during the inspection. What the service does well:
Each resident has a very comprehensive care plan in place with their needs clearly identified and tasks needed to be done in order to meet these needs. Communication amongst the staff is excellent and they have very good and effective methods of ensuring everyone knows what is happening in the home. These include written handover sheets, regular staff meetings and supervision sessions. All relevant records are well maintained and were up to date at the time of the inspection. Residents are encouraged to be independent and regular meetings are held where they can put forward any ideas/concerns that they may have. The ones spoken to during the inspection confirmed that they can go to bed/get up when they choose and are free to go out with relatives or alone according to what has been agreed in their care plan. All residents spoken to confirmed that they are well looked after and feel able to approach the manager and staff to speak to them. They also said that the meals are excellent and that alternatives are offered if they do not like what is on the menu on a particular day. There is a commitment to training and the members of staff spoken to at the inspection confirmed that they are able to have easy access to relevant courses. Several staff members are working on the NVQ awards. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: 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 Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,5 People are able to make an informed decision about the home from the written information they receive and from what they are able to see on their visit to the home. EVIDENCE: A copy of the Service user guide given to all prospective residents was seen by the inspector and found to contain sufficient information to enable the person to make an informed choice about the home. It needs some minor updating but overall meets the standard. Copies of the terms and conditions of the home were seen in individual files and contained all the appropriate information including the number of the room they occupy. The pre and admissions assessments were in the residents’ files and were seen to be very comprehensive, containing sufficient information for staff to know what the needs of people were. In the majority of cases the resident had signed their assessment to say that they agreed with it. Residents spoken to confirmed that they had visited the home prior to their admission. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 Staff are aware of the residents’ needs and there is good communication amongst the staff group. Residents are treated with dignity and their privacy maintained at all times. EVIDENCE: Care plans seen contained the needs of the residents and what tasks were required to be done in order for staff to meet these needs. The plans were clear, concise, easily understood and contained health care and social needs. There was evidence that the plans are reviewed and updated on a regular basis. Risk assessments alongside the coping strategies were in place where appropriate. Residents said that they felt their needs were met and that they were well looked after. Some people said that staff could not do enough for them and that nothing was too much trouble. Relatives of one resident confirmed that they felt their aunt was well cared for and that staff responded quickly to any health care needs. They also said that from what they had seen staff
Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 10 maintained the dignity and privacy of people at all times. Specific requests are met where possible and the relatives spoken to were happy about this. No individual takes responsibility for their own medication and the home has a comprehensive medication policy and procedure in place. Medication records seen at the inspection were all signed and up to date and the storage of drugs was satisfactory. One person takes responsibility for the ordering of medication and explained the system to the inspector. The way the medication was given out to residents was seen to be appropriate. Visits from GPs, District nurses and other healthcare professionals were clearly recorded including the reason for the visit, anything that arose from it and actions required. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 standard(s) 12, 13,14,15 Residents are encouraged to be part of the decision making process within the home and to make choices regarding their own lifestyle. They are able to maintain contact with family/friends where possible and visitors are welcomed at the home. The home provides a good, varied, nutritious diet taking into account individual choices is provided at the home. Some activities are offered at the home. EVIDENCE: Residents meetings are held two or three times per year and ideas put forward to improve/change things within the home. People spoken to confirmed that they feel able to voice ideas they may have and are listened to when they do so. Religious services are held on a regular basis and people are free to join in this if they wish to. Some people go out to their own churches if this is their choice. Residents are free to come and go as they wish providing this is all recorded in their care plan. People spoken to confirmed that they could go to bed/get up at the times they choose. All residents spoken to confirmed that the meals at the home are very good and that they enjoy them. The meal served at the time of the inspection was seen to be well-presented and nutritious in content. Staff were seen to offer residents appropriate help to ensure they were able to enjoy their meal.
Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 12 Menus seen also confirmed that the meals were varied and took into account individual likes/dislikes. A list of activities was seen but many of the residents spoken to felt that there was not enough going on. Staff said that they try to encourage residents to take part in organised activities but many are reluctant to do so. One lady said that she enjoys been taken for a walk by staff as she likes to get some fresh air each day. Peoples’ hobbies and interests are recorded on their care plans so staff are aware of these. When entertainers come from outside the home they are well received by the residents. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16,17,18 Residents and their relatives/friends have their views listened to, taken seriously and action is taken to resolve issues. Residents are protected from abuse and have their legal rights protected. EVIDENCE: The appropriate policies and procedures were seen to be in place and staff confirmed that they had had Adult Protection training. They were aware of what to do if any complaint was made although none have been received in the last year. The complaints procedure is printed in the Service user guide so all residents and their family/friends have easy access to this. Residents confirmed that they feel able to speak to staff if there is anything they are unhappy about and that it is dealt with quickly and appropriately. Residents confirmed that they are able to vote and that staff give any help required to ensure that it is done correctly. Voting is normally by the postal system and staff confirmed that everything was in place for the forthcoming General election. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 23, 25, 26 The home offers a safe, well-maintained environment for the residents who are able to access the garden areas easily if they so choose. EVIDENCE: The home is decorated and furnished to a good standard throughout and the communal rooms offer a safe and comfortable space for the residents. All areas of the home were clean and tidy and nothing was seen during the inspection that could cause a hazard to residents walking around the home. A call system is in place throughout the home. Residents are encouraged to bring their own possessions with them on admission and their rooms are comfortably furnished. The rooms offer sufficient space to ensure residents can follow their own lifestyles and staff were seen to knock on doors before entering. The general appearance of the home is clean, tidy and hygienic although work is required in the laundry to bring this up to an acceptable standard. The
Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 15 manager said that work is planned to take place later this year and a new machine is already in use that sluices dirty/soiled laundry. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Residents are supported and protected by robust recruitment procedures. Staffing numbers and skill mix ensure that the needs of residents can be met. EVIDENCE: The staff numbers were appropriate at the time of the inspection residents and staff confirmed that this is the normal way of working. Staff rosters also confirmed the numbers on duty at any time. A senior member of staff said that extra staff can be called in when required and this was confirmed in a conversation with the manager. Staff files could not be seen but the manager and staff said that written references and CRB checks are obtained before staff start working at the home. Staff spoken to said that they are able to access any relevant training courses and the manager confirmed this. All of the staff are encouraged to do NVQ and are given assistance to complete these. The manager said that all staff receive induction, Adult protection, Data protection and health and safety training. Regular staff meetings are held and minutes are made available for people unable to attend. Talking to staff there appeared to be a clear understanding of each other’s roles and responsibilities and clear lines of accountability. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36, 38 The Home is well managed and the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has many years experience working with older people and is currently working on the Registered Manager’s award. Speaking to residents and staff it was clear that they feel she offers excellent support and is always prepared to listen to new ides. Everyone spoken to felt that they could approach her if they had a problem/concern. Regular formal supervision sessions are in place with written records kept. It was not possible to see records concerned with financial matters but the manager and staff talked about the system that is in place. The policies and procedure manual is readily available to all staff and forms part of each person’s induction programme. Staff spoken to showed an awareness of
Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 18 Health and safety and nothing was seen during the inspection that was deemed to be dangerous to either residents or staff. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 x x 3 x 3 x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 3 3 3 x 3 Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 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 OP28 Regulation 18 Requirement At least 50 of staff must have attained NVQ level 2 or equivalent within target timescales (Previous timescale of 31.03.05 not met) The manager must complete the Registered Managers Award within the set timescales (Previous timescale of 31.03.05. not met) The registered persons must implement a quality assurance system that shows evidence of methods of self-monitoring, self audit, review and action planning.(Previous timescale of 31/12/04. not met) Timescale for action 31.10.05 2. OP31 9 31.10.05 3. OP33 24 01.06.05 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 8 Good Practice Recommendations Accident report forms should be kept in a file not in the book in order to comply with Data Protection. Hollybank Residential Home X00015 J52 S1464 Hollybank V224105 280405 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Aire House Town street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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