Inspection on 17/10/06 for Hollybush House Nursing Home

This inspection was carried out on 17th October 2006.

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

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

Other inspections for this house

Hollybush House Nursing Home 14/12/05

Hollybush House Nursing Home 03/08/05

Hollybush House Nursing Home 20/12/04

Hollybush House Nursing Home 14/07/04

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

CARE HOMES FOR OLDER PEOPLE Hollybush House Nursing Home Corbett Hospital Vicarage Road Stourbridge West Midlands DY8 4AP Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 17th October 2006 11:45 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 Hollybush House Nursing Home DS0000004877.V315575.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. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybush House Nursing Home Address Corbett Hospital Vicarage Road Stourbridge West Midlands DY8 4AP 01384 442782 01384 444734 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) Shaw healthcare Limited Mr Tai Wai David Lo Care Home 24 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (22) of places Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 2 Beds for Dementia Care aged 58 years and over. One service user identified in the variation application dated 23.11.04 may be accommodated at the home in the category LD(E). This will remain until such time that the service users placement is terminated and whilst the home is able to meet her needs. 14th December 2005 Date of last inspection Brief Description of the Service: Hollybush House is a purpose built, single storey nursing home for the elderly with dementia. Hollybush House is privately owned by Shaw Homes. The home has a large open lounge and dining area, a small quiet lounge, activities room and activities kitchen. Televisions and a stereo system are provided in the main lounge. The home has a secure garden with patio area, which is available for all service users. A qualified nurse is on duty twenty-four hours a day, with a Registered Nurse (mental health) available usually on at least one shift during a twenty-four period. The home was designed with service users possible disabilities in mind, and includes wheelchair access, handrails, assisted baths and other adaptations. A full laundry service is also provided free of charge. The home is located in the grounds of the old Corbett Hospital and has car parking available at the side of the home. Fees vary between £451 and £780 and are dependant on the needs of the service user. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken between 11.45 and 19.00. The inspection included a tour of building, a review of records, talking to visitors, service users and staff and time spent observing the service users and staff. Care records were reviewed as part of the “case tracking” of four residents. A review of information supplied by the Manager (pre inspection questionnaire) was also undertaken and expanded upon during the visit. Hollybush House Nursing Home is privately owned by Shaw Homes. The home’s manager is Mr David Lo. Twelve of the previous sixteen requirements were found to have been addressed, no requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 6 The implementation of the new person centred care records and profile has been an excellent innovation giving staff an improved insight into service users interests, needs and life history. . Staff have received additional training in dementia awareness which also includes the management of violence and aggression. Staff receive required supervision and have six monthly appraisals. The manager has sought advice on how the environment of the home can provide stimulation to service users with dementia whilst also maintaining their recollection such as the location of their bedroom and toilets. 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. The summary of this inspection report can be made available in other formats on request. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 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 Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1.6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Significant time and effort is spent making admissions to the home personal and well managed. Prospective residents and their families are treated with dignity, respect and understanding for the life changing decisions that they need to make. EVIDENCE: Service users have a comprehensive assessment of their needs by either the Manager or Deputy Manager prior to agreement by the home that they will be able to meet their needs. It was lovely to see how much detail staff had recorded about the service users life and experiences and how their dementia had affected their life with all care records being “person focused”. It was evident that their family are involved in the assessment of their needs. Relatives spoken to said how impressed they had been by the professionalism, knowledge and sensitivity of staff when they assessed their relative . Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 9 The home has recently completed a temporary trial to accommodate service users requiring intermediate care. The provision of intermediate care has been successful and there are plans to enable the home to accommodate people who require intermediate care on a more permanent basis. Plans are being to developed to provide separate accommodate and a separate staff group for intermediate care. The home did not have any intermediate care service users at the time of this inspection Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home meets service users healthcare and personal care needs and respects their privacy and dignity. EVIDENCE: The home has implemented new “person centred” care records- “Service users person centred care/ support profile”. These records set out a plan of care that is comprehensive and details all service users individual needs which can be consistently met. Care plans are reviewed at least monthly alongside the service user and their relative whenever possible. The home has all required risk assessments which identify when services users are at risk of developing pressure sores, mal nourishment, falls and required moving and handling procedures to enable staff to take appropriate actions to reduce the risk and safeguard service users. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 11 Care records and service users identified that they are appropriately referred to and have visits from Health Professionals such as GPs, specialist nurses, dentists, opticians and chiropodists. Procedures in relation to medicines throughout the home safeguard the health and well being of its services users. Over the period of the inspection staff were observed to interact with residents with respect and sensitively to protect service users dignity. Relatives spoken to said: “ staff here are very good and kind” another relative said “ all the staff are very good all the time”. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily life and social activities of the home meet service users needs, capabilities and preferences. Friends and family feel welcome and know that they can visit the home at any time. Service users enjoy the meals that are served. EVIDENCE: Daily routines at the home are flexible to meet service users needs. The home has two Activity Therapists who assist service users in a number of day to day activities as well as planning social events, games and crafts as part of their plan of care. The Activity Organisers identify individual’s suitability for different activities such as reminiscence therapy, relaxation music group and a sensory group. Staff seek information about service users life history and leisure interests which are then transferred into their plan of care. Families spoken to say that they are encouraged and enjoy, taking part in the various social events that the home holds. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 13 The home actively supports ongoing contact with service user’s friends and relatives. The home had a steady flow of visitors throughout the day (more visitors than ever seen in any other home!), all visitors spoken to state that they are always made welcome by staff. Relatives say that they are regularly updated in relation to any changes/incidents involving service users. The home has an active relatives and friends group that meets regularly Meals are prepared and cooked by an outside caterer and brought into the home on a “cook chill basis”. The home has a four weekly menu, which offers choice and tasty and nutritious food with normal, soft, pureed and diabetic diets available. Breakfast is served from 7.45 until approximately 10.30 am Lunch is served from 12.45 to 13.30. Evening meal is served between 17.00 and 18.00. A milky drink with a light snack is available for supper. Residents and their families are asked for the residents preferences whenever possible. It was also nice to see several visitors visited at lunch time and assisted in feeding their relative and also able to have a drink and meal with their relative. Staff give discreet assistance to service users who need assistance to eat their meals. Staff need to explore how meal times can be made more congenial within the capabilities of service users- consideration needs to be made to the use of table cloths, cruets on the table and cutlery being provided on the table (rather than be stuck into the meal) and the use of appropriately laid trays. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has appropriate policies and procedures to highlight concerns and complaints, to safeguard residents from abuse. EVIDENCE: The home has a detailed complaints procedure, which is displayed in the reception area of the home, is in the service user guide and is also included in the terms and conditions of residency. The home has received one complaint in the last twelve months. Records seen show that a full investigation of the concern highlighted was undertaken concluding that the complaint was not substantiated. Relatives spoken to said if they had any concerns they would not hesitate to discuss them with the Home Manager. The home also has appropriate policies for staff to highlight concerns whilst feeling safe to do so. Staff were seen during the inspection to ensure that other staff maintain the high standards of care within the home. The Manager actively contacts the Commission for Social Care Inspection as is the company policy for advice and to inform them of any concerns. The Adult Protection policy meets current guidance identified within the “No Secrets” legislation. The home also has appropriate policies to ensure that staff who are not suitable to work with vulnerable people do not do so by robust recruitment and selection procedures. A programme of Protection of Vulnerable Adults training has been identified and is ongoing for all staff. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, homely and generally free from offensive odours but does not fully reflect the needs of people with dementia. EVIDENCE: The home is clean, homely and well maintained. There is a large lounge/ dining room with smaller areas off the main lounge and an additional small quiet lounge is also available. All bedrooms are single occupancy with a sink in each bedroom. The home has a full nurse call system and a variety of aids and adaptations such as grab rail assisted baths and a wheel in shower available for dependent residents. The home is on one level enabling resident’s access throughout the home. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 16 Since the last inspection the Home Manager has sought advice on how the environment of the home can best meet the needs of people with dementia. Changes to the home following advice and research has included bedroom doors being painted different colours to aid service users to locate their own room, toilet doors being painted yellow to help orientate them to using the toilet, grab rails painted red to enable residents to hold on to them to reduce the risk of falls and tactile boards. The home has satisfactory infection control procedures to safeguard the service users. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has sufficient and experienced staff to meet service users needs. Recruitment and selection procedures are robust and safeguard the service users. Staff training opportunities are good and assist in achieving good quality care. EVIDENCE: The home is staffed with the following: 07.00-14.30 1 trained nurse and 4 care staff (total of 5 staff) 14.30-21.30 1 trained nurse and 4 care staff (total of 5 staff) 21.00-07.00 1 trained nurse and 3 care staff The Home Manager is not included in care numbers and the Deputy Manager is also usually not included in care numbers. The home also has two Activity Organisers who are also not included in the above staffing levels. Additional domestic, catering and laundry staff are also available. The home has more than the required 50 of care staff with NVQ level 2 or above that demonstrates the commitment of the organisation to providing good quality care by well trained staff. Staff are supported to undertake Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 18 external courses to develop not only their own practice but also the practice of other staff to assist in the delivery in high standards of care. Recruitment and selection procedures within the home are robust and safeguard its residents. Staff have good training opportunities and have a training and development plan developed as part of their appraisal. All staff have at least three training days each year. All new staff receive induction training to National Training Organisation specifications and at least three training days each year. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed and is run in the best interests of the service users whilst also ensuring that they are protected. EVIDENCE: Mr David Lo was appointed as Home Manager in 2005 and has successfully completed a fit person assessment with the Commission for Social Care inspection. Mr Lo has been Deputy Manager of Hollybush House since 1990. Mr Lo is a registered mental health nurse and has National Vocational level four in management and a Health and Safety qualification. He is also currently undertaking his Registered Managers Award. All visitors spoken to state that Mr Lo is approachable and that the home is well managed. This inspection found the home to be efficiently and effectively managed. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 20 The Home Manager is supported by a Deputy Manager and also receives support from Shaw Health Care Senior Managers. Shaw Health Care has an identified Quality plan for the home. Quality audits are undertaken annually with corrective actions identified. The home manager also undertakes three monthly audits of all areas within the home. Relative surveys are undertaken at least six monthly with plans of action identified. Required visits on behalf of the registered company are undertaken. The Manager and registered company proactively identify ways that requirements of Commission for Social Care Inspection will be met. Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Money that was randomly checked in the safe was found to be correct and equal the balance identified. Regular external audits of service users personal money is undertaken. The home has good employment policies in relation to induction of new staff. Supervision is has commenced and is regularly undertaken for all staff. The Home Manager is the regional health and safety advisor having undertaken additional qualifications in health and safety. Regular and required checks are undertaken on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, first aid, health and safety, infection control and the protection of vulnerable adults. Maintenance records and contracts were reviewed and were found to be up to date. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 21 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 x x 4 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 4 11 x 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 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 3 x 2 Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement A date of opening must be recorded on all short life items. Unable to evidence as there are no short life medicines currently in use. The exact amount given of variable dose medication must be identified Partially met- the number of tablets administered is not always recorded Care plans must be available for medicines that are administered on an as required basis. Partially met most care plans did record the use of as required medicine but not all. Staff must receive training in the care of people with dementia, management of violence and aggression de-escalation techniques and first aid. Partially met 24 of 32 staff have received this staff Timescale for action 15/11/06 2 OP9 13(2) 15/11/06 3 OP9 13(2) 15/11/06 4 OP38 18(1) 31/12/06 Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 23 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 OP15 Good Practice Recommendations Meal times could be made more congenial within the capabilities of service users. Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Hollybush House Nursing Home DS0000004877.V315575.R01.S.doc Version 5.2 Page 25 - 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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