Inspection on 23/06/05 for Hollycroft

This inspection was carried out on 23rd June 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.

Other inspections for this house

Hollycroft 23/10/09

Hollycroft 06/09/07

Hollycroft 05/12/06

Hollycroft 06/12/05

Hollycroft 08/12/04

Hollycroft 05/05/04

Hollycroft 15/05/03

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Hollycroft Hebers Ghyll Drive Off grove Road Ilkley LS29 9QE Lead Inspector Steve Marsh Unannounced 23rd June 2005 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. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hollycroft Address Hebers Ghyll Drive Off Grove Road Ilkley LS29 9QE 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) 01943 607698 01943 601609 Acegold Ltd (a wholly subsidiary of Four Seasons Health Care Ltd) Mrs Susan Enid Walters Care Home Only 30 Category(ies) of Old age (30) Dementia Over 65 (3) Physical registration, with number Disability Over 65 (3) Mental Disorder Over 65 of places (1) Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: That the category of MD(E) be used for the service user named on the application signed on 12th May 2004 Date of last inspection 08/12/04 Brief Description of the Service: Hollycroft Care Home is situated on Hebers Ghyll Drive, about one mile from Ilkley town centre with its variety of shops, restaraunts and other amenities. The home a former private residence is a large Victorian property, which as had an extension and a conservatory added to the existing building in recent years. The home stands within well-maintained grounds and there is limited parking to the front and side of the property. Hollycroft is registered to care for thirty residents in both single and double bedrooms located on all three floors of the property. Many of the rooms have en-suite facilities and there is a passenger lift available to the upper floors. All the communal areas used by the residents including the lounges and dining room are situated on the ground floor of the home, and there is ramped wheelchair access to the building to assist residents and/or visitors with mobility problems. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection for the year 2005/06, and was carried out by one inspector over a period of approximately eight hours. The last inspection of this service was in December 2004 and the main purpose of this visit was to assess the homes progress in meeting the requirements and recommendations highlighted in the inspection report. The methodology used in this inspection included the examination of records, observation of work practices, discussion (group and individual) with residents, visitors, staff and management and a partial tour of the building. Comment cards were provided for the residents and/or their relatives to enable them to share their views of the service with the Commission; comments received in this way will be fed back to the registered manager of the home without revealing the identity of the respondents. The Inspector has visited Hollycroft Care Home over a period of approximately four years and therefore drew on information already known about the home when completing this report. People living at the home confirmed that they prefer to be referred to as residents in inspection reports. Feedback was given to Mrs Susan Walters (Registered Manager) at the end of the visit. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: The home provides a safe and comfortable environment for the residents, and all concerns/complaints are taken seriously by the manager and acted upon. The manager and members of the staff team are approachable, have a caring attitude and create a homely atmosphere for the resident. The admission procedure for the home is thorough and the manager will not admit a resident unless she feels that the staff team can provide the level of care/service they require. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 6 The resident’s healthcare needs are met, and any problems are identified at an early stage and a referral made to the appropriate professional agency. Members of staff encourage the residents to make as many decisions as possible in relation to their daily lives, and activities and outings are organised in line with their wishes. 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 Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 7 contacting your local CSCI office. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 Residents are provided with sufficient information to enable them to make an informed decision about the home. The admission process is good and includes pre-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: A copy of the homes brochure and supporting information made available to all prospective residents was seen, and found to contain sufficient information to enable the resident and/or their relatives make an informed decision about the home. The records examined provided evidence that pre-admission assessment visits are carried out to see prospective residents, and the needs identified during this visit are reflected in the individuals care plan. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 10 The majority of admissions are planned, although the home continues to respond to crisis situations and will take emergency admissions providing the staff team can meet their needs. In addition to the pre-admission visit all prospective residents and/or their relatives are invited to visit the home prior to admission, to view the accommodation, meet the staff and other residents and stay for a meal if they wish to do so. Residents are also able move in to the home for a trial period or for a short stay to enable them to consider their long-term future. Residents confirmed that the staff had been very helpful when they or their relatives had initially visited the home looking for a place, and had shown them around and provided general information. One resident also confirmed that he had recently moved in to the home on a trial period and while he was very happy with the standard of care provided. He was also pleased that no pressure had been put on him to make a decision about his long-term plans has he did not feel able to do so at the present time. Staff training continues to be encouraged at the home both to meet the needs of the residents and for personal development. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Records and reports about the residents welfare show that their healthcare needs are met, and any problems are identified at an early stage and a referral made to the appropriate professional agency i.e. general practitioner, district nurse etc. EVIDENCE: Care plans have been completed for all residents and cover all aspects of their welfare. The care plans are reviewed on a monthly basis or sooner if the needs of individual residents change significantly, and risk assessments are completed for specific areas of concern. The manager confirmed that as recommended in the last inspection report the senior staff team had looked at how care plans were presented, and it was noticeable that information was now more easily accessible, and the system more user friendly. All the residents are registered with a general practitioner from one of the two local surgeries in Ilkley, and have access to the full range of NHS services. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 12 The residents confirmed that prompt medical assistance is provided if required and a record is kept of visits made by general practitioners and other healthcare professionals. Residents confirmed that medical examinations were carried out in private, they were treated with respect at all times and members of staff maintained their dignity when assisting them with personal care. Evidence of this was seen throughout the day of the visit as staff dealt with the needs of the residents in a discreet and sensitive manner. At the present time only one resident administers his own medication, however, all new admissions to the home are able to keep control of their medication provided they have the capacity to do so. On reviewing the medication system in place no concerns were raised and members of senior staff were observed to give out medication in a correct manner. The staff team continue to monitor the general health of residents taking long term medication and advice is sought from their general practitioner and/or the supplying pharmacist if they have any concerns. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 13 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) 12,14,15 The home offers a range of social and leisure activities, and residents are encouraged to make informed decisions about their lifestyle. Meals appear nourishing, and take into account the likes and dislikes of individual residents. EVIDENCE: The daily routines of the home appear flexible and are based around the needs of the residents. The home does not employ an activities co-ordinator therefore it is the responsibility of the care staff team to organise activities/outings for the residents. Residents are encouraged to continue with the social and leisure activities they enjoyed prior to moving into the home and a number of residents confirmed that they enjoyed the freedom of being able to organise their daily lives. The home is fortunate to have its own mini bus and twice weekly trips are organised to places of interest. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 14 The residents are also encouraged to follow their religious beliefs and a lay preacher was holding communion at the home on the day of the visit. The manager holds a small activities budget, however the staff team also hold funding raising events to provide additional entertainment, outings and activities for the residents. Residents appeared happy with the level of activities/outings organised and some were looking forward to a canal boat trip arranged for August 2005. Menus at the home continue to rotate on a four weekly basis and with the exception of breakfast, which is served in their rooms, meals are served in the pleasant dining room on the ground floor of the home. Residents confirmed that the meals provided are very good and an alternative choice was always made available to them if they did not like what was on the menu for the day. Hot and cold drinks are freely available to the residents both day and night. Residents have input into menu planning, arranging social activities and other aspects of the service through the meetings held with the manager and/or staff on a six monthly basis. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 15 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) 16,18 Robust complaint and adult protection policies and procedures, ensure that residents are listened to, and protected from any form of abuse. EVIDENCE: The home has a complaints procedure and residents spoken to confirmed that they were aware of the procedure and knew what to do of they were unhappy with the standard or care or service they received. One complaint has recently been made directly to the Commission for Social Care Inspection and the home is presently co-operating with the Commission to resolve the matter. Policies and procedures are in place at the home in relation to adult protection, and all members of staff are currently completing in-house training using the training material and workbooks provided by Four Seasons Health Care. The manager confirmed that she is also aware of the Protection of Vulnerable Adult register introduced in July 2004 and the procedures to be followed should the need arise to contact the agency. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 16 Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 17 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) 19,20,21,23,24,26 The home has a planned programme of refurbishment/renewal and Four Seasons Health Care continue to make a substantial financial commitment to improving and maintaining the facilities available to the residents. EVIDENCE: Internally and externally the home is very well maintained and there is an on going programme of refurbishment and renewal. All the communal areas used by the residents including lounges and the dining room are situated on the ground floor of the home, conveniently close to communal toilet and bathroom facilities. There is also a pleasant conservatory with patio doors leading out to the garden, which can be reached through the lobby area. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 18 Bedrooms are located on all three floors of the home and consist of both single and double rooms, many of which have en-suite facilities. Bedrooms are very well furnished and residents are encouraged to bring personal possessions into the home, which makes each room look individual and homely. Information previously made available to the Commission for Social Care Inspection shows that two double bedrooms are below the required size for shared accommodation. However, the manager confirmed that these rooms continue to be occupied by residents who prefer to pay enhanced rates for more spacious accommodation and it is not anticipated that they will be used again as double rooms. Residents confirmed that they were very happy with the standard of accommodation at the home, and said that they were always consulted about the colour scheme if their bedrooms are redecorated, carpeted or new soft furnishings purchased. On the day of the visit the home was clean and tidy and no odour problems were noted. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 19 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) 27,28,29,30 Although Four Seasons Health Care has taken steps to address the staffing problems at the home, the manager must ensure that she is involved in the recruitment and selection of overseas workers. A recent training audit completed by the manager has highlighted gaps in the training needs of the staff team, and positive action is now being taken to ensure that training is provided in line with the needs of the residents. Additional training for overseas workers to improve their communication skills must be made available to them if required, to safeguard the residents. EVIDENCE: The home has in the past experienced some difficulty in recruiting staff and has therefore recently employed five overseas workers from Poland on two year contracts. All overseas workers are employed through the Four Seasons Health Care overseas recruitment department, however the manager is not involved with their recruitment and selection. On speaking to three Polish workers employed as care assistants, no concerns were raised regarding their commitment to care for the residents to the best of their ability, but certainly for one member of care staff there was a concern about his ability to understand written English. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 20 The manager must therefore ensure that to safeguard the residents all members of staff are able to not only read, but also understand all records and reports relating to their care, and provide additional training if required. The arrival of the five overseas workers does however means that the home no longer has to employ agency staff and the residents are cared for by familiar faces. Although all new members of staff have commenced induction training, the manager was reminded that to meet the National Minimum Standards this training should have been completed within six weeks of appointment to the post. The home has experienced some difficulty in providing the care staff with National Vocational Qualification (NVQ) training, and at present only two members of care staff has achieved the qualification at level two. All members of staff providing personal care are over eighteen years of age, and all senior members of staff are over twenty-one years of age. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 21 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) 31,36,38 Although the manager has not yet commenced studying for a NVQ at level four, she is very competent and has the skills and experience to manage the home. Policies and procedures are in place to ensure the health and safety of the residents, visitors and members of the staff team. EVIDENCE: Mrs Susan Walters is the registered manager of Hollycroft Care Home and she communicates a clear sense of direction and leadership to the staff team. Mrs Walters is a competent manager but has unfortunately not yet started to study for a National Vocational Qualification at level four in management and care, which is the recognised qualification for the post she holds. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 22 Members of the staff team confirmed that Mrs Walters has an approachable and open management style and supports them in their work. Staff also said that they enjoyed working at the home, and all the staff work together as a team for the benefit of the residents. Regular staff meetings are held at the home to ensure that information is made available to all members the staff team, and one to one supervision is carried out with individual members of staff on a two monthly basis. Residents meetings are also held approximately every six months, and residents confirmed that the manager kept them informed of any changes to the daily routines of the home, which may affect them. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff, and they are audited and reviewed on a regular basis to ensure that they meet with present legislation. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 23 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 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 4 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x x 3 x 3 Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 24 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 OP27 Regulation 19(5) Requirement The registered manager must ensure that all members of staff are able to communicate effectively with the residents, and are able to complete and understand records and reports relating to their care. A minimum of 50 of the care staff team must complete NVQ training at level two by 2005. The registered manager must ensure that she is more involved in the recruitment and selection of overseas workers. The registered manager must ensure that new members of staff receive induction training in line with the National Minimum Standards. The registered manager must complete NVQ at level four in management and care by 2005. Timescale for action 31/08/05 2. 3. OP28 OP29 18 18 31/12/05 31/08/05 4. OP30 18 31/08/05 5. OP31 9(b)(1) 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. Hollycroft Refer to Good Practice Recommendations J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 25 Standard 1. Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 26 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 Hollycroft J52 J03 S1218 Hollycroft V210007 210605 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!