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Inspection on 09/11/05 for Hollybank Residential Home

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

This inspection was carried out on 9th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

All residents have a comprehensive care plan in place that they sign to say they agree with. The plans clearly identify the residents` needs and the tasks staff need to do in order to meet these needs. Communication amongst the staff is of a high standard and good interactions were seen between them and residents during the inspection. Regular staff meetings and supervision sessions are in place and all records were correctly maintained. Residents are encouraged to be part of the decision making process at the home and the manager holds regular meetings with them. They are able to put forward any ideas or concerns they may have. People spoken to during the inspection said that they are well looked after and that staff are always polite towards them. Residents are able to get up and go to bed at the times they choose and can go out with family and friends if this is agreed in the care plan. Everyone said that the meals are very good and that they are offered a choice. There is a commitment to training at the home and staff are working towards National Vocational Qualifications. Staff said that they are able to request to attend relevant training courses and are normally allowed to. Staffing numbers and skill mix are appropriate for the present group of residents.

What has improved since the last inspection?

Accident report forms are now stored in the correct way. A quality assurance system has been introduced at the home although due to the absence of the manager it could not be seen at the inspection. Work has started on the laundry to bring it up to the required standard. More staff have completed NVQ level 2. The Service User Guide and Statement of Purpose have been updated.

What the care home could do better:

Residents` wishes following their death should be recorded in their own file. The manager must complete the Registered managers` award by the end of the year. 50% of the care staff must complete the NVQ level 2 award as soon as possible.

CARE HOMES FOR OLDER PEOPLE Hollybank Residential Home 321 Chapeltown Road Leeds West Yorkshire LS7 3LL Lead Inspector Kathleen Firth Unannounced Inspection 09/11/0 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.V260621.R01.S.doc Version 5.0 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.V260621.R01.S.doc Version 5.0 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 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 DS0000001464.V260621.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 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. The home’s staff do not provide nursing care 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 DS0000001464.V260621.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two hours by one inspector on Wednesday 9th November 2005. The inspector looked round the building, examined residents’ records including care plans, menus, staff rosters and medication records. Staff and residents were all helpful during the inspection process and joined in. Five residents, three staff members and the manager were spoken to. The manager was not present during the inspection but the inspector spoke to her on the phone. A senior care assistant was present to help the inspector. What the service does well: What has improved since the last inspection? Accident report forms are now stored in the correct way. A quality assurance system has been introduced at the home although due to the absence of the manager it could not be seen at the inspection. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 6 Work has started on the laundry to bring it up to the required standard. More staff have completed NVQ level 2. The Service User Guide and Statement of Purpose have been updated. 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 DS0000001464.V260621.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 4, 6 People can be sure that their needs can be met at the home following an assessment of need. EVIDENCE: The Service User Guide and Statement of Purpose have been updated since the last inspection. The information people gain from these plus what they learn on their visit to the home helps them make an informed decision about coming to live there. All prospective residents have a needs assessment done by the manager prior to a decision being made about their admission to the home. The pre admission information is in their file and offers the manager and staff sufficient information to decide if they can meet the person’s needs. Anyone deciding to live at the home can be sure that his or her needs will be met. Families can also be sure that the home will care for their relative in a professional way and meet all of their needs. The home does not provide Intermediate Care at this time. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 9 Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 10,11 Staff show a good awareness of residents’ needs and there is good communication amongst them. Residents are treated with dignity and their privacy is maintained at all times. Their wishes following death are respected. EVIDENCE: All of the residents have a comprehensive care plan detailing their physical, social and spiritual needs. Alongside these needs are the tasks staff need to do in order for them to be met. Specific instructions and any allergies are clearly recorded. Evidence was seen that the residents sign to say they agree with their care plan and that the plans are reviewed and updated on a regular basis. None of the present residents manage their own medication and the home has a policy and procedure in place to deal with this. All records concerned with medication were correctly maintained. Evidence was seen that if a particular medication is withdrawn or a course completed this is clearly recorded. All medication changes are recorded in the front of the medication file. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 11 Residents spoken to said that the staff treat them with respect and acknowledge their privacy. Staff knock on bedroom doors before entering and any personal care is delivered in an appropriate way. Any post is given to the residents and help given to deal with this if required. People can stay at the home until their death if this is thought to be the most suitable course of action. Discussions are held between the resident, GPs, relatives, staff and any specialist personnel that may be needed. Relatives are able to stay at the home overnight if this is their choice. The manager records people’s wishes following their death in a separate book but it was suggested that these should be in the residents’ main file. It was acknowledged that if anything contained in these wishes is confidential then this does not need appear in their file. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Residents are encouraged to be part of the decision making process at the home and to make choices about their own lifestyle. They are able to maintain contact with family and friends. The home provides a good, nutritious and varied diet that takes into account individual preferences. EVIDENCE: The home provides some activities for the residents and those spoken to said that they have enough to do. The residents enjoy the musical entertainer who comes to the home on a fairly regular basis. Activities’ records showed various things that had been arranged and which residents had taken part in them. A religious service is held at the home on a regular basis and people are able to take part in this if they so choose. Some residents continue to attend their own place of worship. Residents confirmed that their friends and relatives are able to visit them and are always made welcome by the staff. If agreed in their care plans residents are free to go out with their family and friends. Choirs from the local community are due to visit the home over the coming Christmas period. Regular meetings are held with the residents where there is an agenda that everyone can add items to. Minutes are taken at these meetings and made Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 13 available to everyone. Residents are encouraged to take part in the meetings and to contribute their ideas. People are able to go to bed and get up at the times they choose. If help is required to do this then their preferred times are recorded so that staff are aware of them. The home provides a good, nutritious and varied diet that takes into account the individual resident’s preferences. The meal served at the time of the inspection was nicely presented and nutritious in content. Residents confirmed that the meals are very good and that they are offered an alternative if they do not like what is being served on the day. Staff offer residents help to make sure that they are able to enjoy their meals. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Residents and their relatives/friends have their views listened to, taken seriously and appropriate action taken to resolve them. Residents are protected from abuse. EVIDENCE: The home has appropriate policies and procedures in place to deal with Complaints and Adult Protection. There have been no complaints since the last inspection. Residents, family and friends are able to access the complaints procedure easily as it is contained in the Service User Guide. All of the people spoken to during the inspection said that they are able to speak to the manager or staff if they have any concerns or worries. Staff have received Adult Protection training and are able to recognise the signs and symptoms of abuse. All of the residents are registered to vote and are able to have help to do so. They usually use the postal system but staff can take them to the polling station if they prefer to do this. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 26 The home offers a safe, well-maintained and homely environment for the residents. There are sufficient toilets and bathrooms for the residents’ use. EVIDENCE: The home is furnished and decorated to a good standard and the communal rooms are comfortable and big enough to accommodate all of the residents. All areas of the home were clean and tidy and no unpleasant odours were present. A new kitchen has been fitted since the last inspection and this is of a very high standard. Staff are very happy with this and said that it is much easier to work in. The laundry is being upgraded at the present time. A maintenance man is available to carry out emergency repairs in addition to routine work. There are sufficient toilets available for the residents. These were all seen to be big enough for the residents who may need to use mobility aids. Soap and towels were seen in each toilet. Assisted bathing facilities and a walk in shower are available at the home. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 16 Residents can be assessed for any specialist equipment they may need to help retain their independence. The bedrooms are of different sizes but all meet the standard and are well furnished. Residents are encouraged to bring their own possessions in order to personalize their rooms and examples of this were seen. There is a lockable drawer or cupboard in every room and residents are able to lock their room if they choose although not many do so. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30 Staffing numbers and skill mix make sure that the residents’ needs are met. Staff are trained to do their job. EVIDENCE: The staffing numbers were sufficient at the time of the inspection and rosters looked at for a period of time confirmed this to be normal practice. Staff and residents spoken to all confirmed that there is normally enough staff on duty. Extra staff can be made available if required. Residents said that the staff are all very nice and look after them very well, nothing being too much trouble for them. Training is felt to be important at the home and staff can access relevant courses. All staff attend Induction training plus Adult Protection, Data Protection and Health and Safety. They are encouraged to attend training and staff appreciate this. Most of the staff are working towards NVQ level 2 and one member of staff spoken to has recently achieved this and is hoping to start level 3. Regular staff meetings are held and the agenda and minutes are available to all staff. The manager tries to hold the meetings at times convenient to most staff. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, 37, 38 The home is well managed and the interests of the residents seen as important and safeguarded at all times. Health and Safety is promoted within the home. EVIDENCE: The manager has many years experienced working with older people and is currently working towards the Registered manager’s award. Staff and residents spoken to all feel that she offers them good support and is ready to listen to ideas they may have. Everyone spoken to said they are happy to speak to her if they have any concerns or worries. Formal supervision sessions are in place with written records. The policies and procedures file is available for all staff and there is no excuse for any of them to not know about anything. This forms part of their induction so staff are made familiar with the home’s practices from the day they start working there. All records seen during the inspection were correctly maintained and stored in Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 19 a safe way. Residents and their relatives are made aware that they can see their records. The manager holds responsibility for Health and Safety at the home but all staff are made aware of the procedures and receive training in this area. Fire bells are tested weekly and fire drills and training sessions are held as required. Nothing was seen during the inspection that could cause hazard to residents, staff or visitors. Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 20 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 3 Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 21 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 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) Timescale for action 31/12/05 2. OP31 9 31/12/05 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 OP 11 Good Practice Recommendations Residents’ wishes following their death should be recorded in their file Hollybank Residential Home DS0000001464.V260621.R01.S.doc Version 5.0 Page 22 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 © 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.V260621.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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