Inspection on 06/12/05 for Hollycroft

This inspection was carried out on 6th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hollycroft 23/10/09

Hollycroft 06/09/07

Hollycroft 05/12/06

Hollycroft 23/06/05

Hollycroft 08/12/04

Hollycroft 05/05/04

Hollycroft 15/05/03

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Larchfield Manor

Hawkhills

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The Grove Waltham

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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 West Yorkshire LS29 9QE Lead Inspector Steve Marsh Unannounced Inspection 6th December 2005 09:30 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 Hollycroft DS0000001218.V266390.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. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hollycroft Address Hebers Ghyll Drive Off Grove Road Ilkley West Yorkshire LS29 9QE 01943 607698 01943 601609 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) Acegold Limited (a wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Susan Enid Walters Care Home 30 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (30), Physical disability over 65 years of age (3) Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the category of MD(E) be used for the service user named on the application signed on 12 May 2004 23rd June 2005 Date of last inspection 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, restaurants and other amenities. The home a former private residence is a large Victorian property, which has had an extension and 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 DS0000001218.V266390.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection visit 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 June 2005 and the main purpose of this visit was to assess the homes progress in meeting requirements highlighted in the inspection report. The methods used during this inspection included the examinations of records, observation of work practices, discussions, (group and individual) with residents, staff and management, and a partial tour of the premises. Comment cards were left 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 respondent. 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. 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 continues to provide a safe and comfortable environment for the residents. The admission procedure is thorough and the manager will not admit a resident unless she feels the staff team can provide the level of care and/or services they require. Residents are treated with respect and are encouraged to make as many decisions as possible in relation to their daily lives. The manager and staff appear approachable, have a caring attitude and create a warm and homely atmosphere for the residents. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 6 All complaints about the service are taken seriously and action is taken to resolve matters. 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. Hollycroft DS0000001218.V266390.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 Hollycroft DS0000001218.V266390.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): 1,2,3,5 Residents are provided with sufficient information to enable them and/or their relatives make an informed decision about the home. The admission procedure is good and includes pre-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: The manager confirmed that there had been no changes to the homes statement of purpose and service user guide, which are available to both current and prospective residents. The records reviewed showed that pre-assessment visits are carried out to see prospective residents, and the needs identified during this visit are reflected in their initial care plan. The majority of admissions are planned although the home continues to respond to crisis situations, and will take emergency admissions provided the manager is sure the staff team are able to meet their needs. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 9 In addition to the pre-admission assessment visit, prospective residents and/or their relatives are also invited to visit the home prior to admission, and are able to move into the home for a trial period if they wish to do so. Residents spoken to confirmed that they or their family had visited the home prior to admission, and had been made to feel very welcome by the manager and staff. The manager confirmed that residents receive terms and conditions of residence on admission, which have recently been reviewed and updated. The home does not provide intermediate care. Hollycroft DS0000001218.V266390.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): 7,8,10 The care plans in place are completed to a good standard, however the manager must ensure that they are reviewed at least monthly. Residents are treated with respect, and their healthcare needs are monitored and fully met. EVIDENCE: Care plans are available for all residents, and there is sufficient evidence in the records completed to show that the residents and/or their relatives are involved in the care planning process. The care plans looked at were clear, easily understood and contained both the healthcare and social needs of the residents as well as a good life history. In addition to the care plans, risk assessments are also completed for specific areas of concern, and give guidance to the staff on how to manage identified risks. The manager confirmed that care plans are reviewed on a monthly basis or sooner if the needs of individual residents change significantly. However, three care plans looked at on the day of the visit had not been reviewed for at least two months and therefore this matter must be addressed. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 11 All residents continue to be registered with a general practitioner from one of the two local surgeries in Ilkley, and have access to the full range on NHS services. The home has good working relationships with other healthcare professionals i.e. general practitioners, district nurses etc, and the residents confirmed that prompt medical attention was always provided if required, which they found very reassuring. The manager confirmed that relatives are kept informed of any changes in the resident’s general health, and are encouraged to discuss their healthcare care with other healthcare professionals if they wished to do so. Residents confirmed that medical examinations are always carried out in their own bedrooms, and it was obvious through observation and discussion that the staff treat the residents with respect, and maintain their dignity when assisting them with personal care. Hollycroft DS0000001218.V266390.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 The home continues to offer 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 residents likes and dislikes. 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 continue to be encouraged to participate in the social and leisure activities they enjoyed prior to moving into the home and make decision about their daily lives. The home is fortunate to have its own mini-bus and twice weekly trips are organised to places of interest in line with the resident’s wishes. Residents confirmed that they had especially enjoyed a canal boat trip during the summer months and were looking forward to the Christmas festivities. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 13 Shopping trips to Ilkley are arranged for either individuals or groups of residents, and entertainers visit the home on a regular basis. Residents confirmed that they are able to see visitors in their own room if they wish to do so, and visitors were always made to feel very welcome by the staff and offered light refreshment. The meals at the home were described by the residents has good in both quality and presentation and they confirmed that an alternative was provided if they did not like what was on the menu. Residents requiring assistance/prompting with their meals receive the support and assistance needed to ensure that they eat a nutritious and balanced diet. Hot and cold drinks are freely available to the residents both day and night. Residents continue to have input into menu planning, arranging social activities and other aspects of the service through the meetings held with the manager and staff on a six monthly basis. Hollycroft DS0000001218.V266390.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 Robust complaint and adult protection policies and procedures, ensure that residents are listened to, and protected from any form of abuse. The resident’s legal rights are upheld and independent advocates are sought for individual residents if appropriate. EVIDENCE: A detailed complaints procedure is available and residents confirmed that they would initially speak to the manager if they had any worries or concerns. One complaint referred to the Commission earlier in the year has now been satisfactorily resolved, and records reviewed indicated that two complaints received by the home since the last inspection visit, had been dealt with appropriately by the manager. Policies and procedures are in place at the home in relation to adult protection, and all members of staff have either completed, or are in the process of completing in-house training using the workbooks provided by Four Seasons Health Care. Members of staff spoken to said that they were aware of the homes policy on “whistle blowing” and their responsibility to safeguard the residents from any form of abuse. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 15 The manager is aware of the Protection Of Vulnerable Adults register introduce in July 2004, and the procedures to be followed should the need arise to make a referral to the agency. The manager confirmed that if appropriate residents are made aware of independent advocates who will advise and act in their best interest, and are encouraged to participate in the political process by voting at both local and general elections. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 16 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): 19,24,25 Four Seasons Health Care have made a substantial financial commitment to improving/maintaining the high standard of accommodation and facilities provided at the home. EVIDENCE: At the present time the home is in the middle of an extensive programme of refurbishment and renewal, which is due to be completed prior to Christmas 2005. The programme includes decorating and replacing carpets, curtains and furnishing in all communal areas, and replacing the carpet on the main staircase and corridors. In addition, new lighting is also to be provided in some areas of the home, however concerns about some of the electrical wiring as delayed fittings being replaced. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 17 The older part of the building is therefore to be re-wired, and copy of the new electrical wiring certificate will be forwarded to the Commission on completion of the work. Because of the work taking place a full tour of the building was not made on this visit, however it was noted that the carpet in one single bedroom on the 1st floor of the home (identified to manager) required replacing as part of the refurbishment programme as it is badly worn. In addition, the floor covering in the en-suite facility in this room also requires replacing to provide a non-slip surface. Although there is obviously some disruption to the day-to-day running of the home while the refurbishment work is taking place, the manager is ensuring that the health and safety of the residents and staff is protected, and disruption is kept to a minimum. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 18 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): 27,28,29,30 Residents are supported and protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. However, to safeguard the residents the manager must ensure that if required overseas workers improve their communication skills. EVIDENCE: A rota for the week of inspection was taken, which showed that sufficient care and auxiliary staff are employed to meet the needs of the residents, and keep the home clean and free from offensive odours. All members of staff providing personal care are over eighteen years of age and all senior members of staff left in charge of the home are over twenty-one years of age in line with the National Minimum Standards. Staff recruitment and selection procedures are thorough and the manager confirmed that all new members of staff receive induction and foundation training. However, it was noted that four overseas staff already employed as care assistants for a period of about nine months, had still not completed their induction training. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 19 On discussing this matter with the manager it is apparent that the staff in question are still experiencing some difficulty grasping the language, with at least one individual being unable to read or write in English. As this problem was also identified during the last visit to the home, the manager must now take urgent steps to safeguard the residents by ensuring that all members of staff are able to communicate effectively. Staff training continues to be encouraged at the home both to meet the needs of the residents and for personal development, although at present only one member of care staff has achieved a National Vocational Qualification (NVQ) at level two. Two further members of staff are currently studying for the qualification. Four Seasons Health Care has however established a NVQ assessment centre with assessors and internal verifiers, and the manager confirmed that more emphasis is now being placed on NVQ training. On the day of the visit all the staff on duty responded well to the residents, and were seen to offer reassurance and assistance in a discreet and sensitive manner. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 20 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): 31,32,33,35,36,38 Although the manager has not yet commenced studying for a NVQ at level four in management and care, she is very competent and committed to providing the residents with a quality service. The health and safety of the residents, staff and visitors is promoted and protected by the policies and procedures in place. EVIDENCE: Mrs Susan Walters continues to be the registered manager of Hollycroft Care Home and she communicates a clear sense of leadership and direction to the staff team. Although a very competent manager Mrs Walters has not yet started to study for a National Vocational Qualification (NVQ) at level four in management and care, which is the recognised professional qualification for the position she holds. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 21 Residents and staff confirmed that the manager is approachable and as she works in the home on a daily basis is available to answer any quires and/or concerns they may have. The manager ensures clear lines of communications with the staff by holding staff meetings and one to one supervision is carried out with individual members of staff on a two monthly basis. Residents meeting are also held about every six months, and the residents spoken to confirmed that the manager always kept them informed of any changes in the daily routines of the home, which may affect them. Recognised quality assurance monitoring systems are in place at the home, and the results of a recent survey published by Four Seasons Health Care showed that 94 of the of the residents completing the questionnaire felt that the standards of care provided in the home were good or excellent. Money is held in safekeeping for a number of residents and all transactions are recorded, indicating income, expenditure and a balance. At present no valuables are kept for residents, however this service could be offered if required. Policies and procedures are in place to ensure the health and safety of the residents, staff and visitors, and they are audited and reviewed on a regular basis to ensure that they meet with present legislation. Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 22 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 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 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 3 18 3 3 x x x x 2 2 x STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 3 x 3 Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 23 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 OP7 Regulation 15(b) Requirement The registered manager must ensure that care plans are reviewed on at least a monthly basis. The carpet in the single room identified to the manager on the day of the visit must be replaced. The floor covering in the en-suite facility in this room also requires replacing to provide a non-slip surface. The registered manager must ensure that a copy of the new electrical wiring certificate is forwarded to the Commission on completion of the outstanding work. 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. Outstanding from last inspection report - timescale 31/08/05 not met A minimum of 50 of the care DS0000001218.V266390.R01.S.doc Timescale for action 31/01/06 2 OP24 16(2)(c) 31/01/06 3 OP25 23 31/01/06 4 OP27 18 31/03/06 5 Hollycroft OP28 18 31/12/05 Page 24 Version 5.0 6 OP30 18 7 OP31 9(b)(1) staff team must achieve a NVQ at level two (or equivalent) by 2005. The registered manager must ensure that all new members of the care staff team receive induction training in line with the National Minimum Standards. Outstanding from last inspection report – timescale 31/08/05 not met. The registered manager must achieve a NVQ at level four in management and care by 2005. 31/03/06 03/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hollycroft DS0000001218.V266390.R01.S.doc Version 5.0 Page 25 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 DS0000001218.V266390.R01.S.doc Version 5.0 Page 26 - 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. 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