Inspection on 17/02/06 for Hollygarth

This inspection was carried out on 17th February 2006.

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

Hollygarth 03/07/08

Hollygarth 06/11/06

Hollygarth 12/08/05

Hollygarth 12/11/04

Hollygarth 27/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Hollygarth 80 Roman Road Linthorpe Middlesbrough TS5 5QE Lead Inspector Christine Moon Announced Inspection 17th February 2006 10:30 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 Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 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. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hollygarth Address 80 Roman Road Linthorpe Middlesbrough TS5 5QE 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) 01642 821361 Mr G West Mrs S West Mrs Susan West Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 2005 Brief Description of the Service: Hollygarth is a large, two storey detached Edwardian house situated in a residential area of Middlesbrough and which has been converted into a care home for 12 service users. Close to local amenities and accessible for public transport, the home stands in its own grounds which contain mature tress, providing privacy to the home itself, and an attractive outlook for service users. Accommodation is provided in eight single rooms and two double rooms. Communal areas consist of a large lounge, which is light and airy and has a view over the garden, and a smaller, second lounge which can accommodate service users who may wish to watch television. The dining room is at the back of the home, next to the kitchen, and this room can be used for activities. There is an enclosed patio area to the rear of the home, which is sheltered and which provides seating for service users when weather permits. A lift gives access to the upper floor. The home is comfortably furnished and residents are able to personalise their rooms according to choice and taste. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place over four hours spent in the home on one day. During this time, records were examined and time was spent in discussion with both home managers and service users. This second Inspection completes the two statutory inspections for the current year, and completes assessment of all key standards as directed by the Department of Health. What the service does well: What has improved since the last inspection? New bathroom furniture has been purchased for the downstairs bathroom. There is increased attention to health and safety within the home following the involvement of one of the proprietors. Work has begun to upgrade care plans and risk assessments. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 6 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. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 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 Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 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): 3 The manager and deputy manager ensure that needs are assessed prior to admission to the home. EVIDENCE: Discussion with the manager and deputy manager of the home confirmed that they are aware of the need to ensure that full and comprehensive assessment of need takes place, prior to any admission to the home. To facilitate this process, a Pre-admission Assessment form has been devised, information from which can then be transferred into a Care Plan. When possible, provided that the admission is not an emergency, assessment visits are made to service users, in order to avoid inappropriate admissions. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Care plans are currently being developed to ensure that both care and social needs are detailed in a way which ensure that they can be used as ‘working documents’. The home has policies and procedures in place for the administration of medication which are explicit. Medicine is securely stored in a locked cabinet within the home. EVIDENCE: At the time of the Inspection, new style Care Plans were in the process of being developed for all residents and these Plans will include more detailed Risk Assessments. Confirmation was seen that any specialist, individual need is now being included in a Care Plan, for example, in the case of dietary need. Completion of this task, which is currently underway, will ensure that all Care Plans are explicit and can be used as working documents by staff, in order to inform all care provided. The manager said that all new Care Plans will contain a nutritional assessment. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 10 The home has a policy in respect of the administration of medication. If appropriate following a risk assessment, service users are able to retain responsibility for their own medication. Medication is safety stored in a locked cupboard within the home. Following a visit from a Primary Care Trust pharmacist, any controlled drugs are stored separately in a locked box, and a separate log, which is signed, is kept in respect of this. All staff, apart from one, have completed Safe Handling of Medication training. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Service users living at the home definitely feel satisfied with their lives at Hollygarth. EVIDENCE: On the day of the Inspection, time was spent having lunch with service users and talking with them about their views of the home. All spoken with said they were ‘very happy’ and said that they also enjoyed social activities and outings which are on offer. Motivation sessions are available on a monthly basis, provided by an independent company. In addition, those who are able to enjoy outings from the home, which may take the form of either shopping trips, or calling at cafes or restaurants for coffee and light meals. The manager and staff are conscientious about enabling residents to maintain their independence, and where possible support is offered to enable this to happen. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 12 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 and 18 Complaints are listened to and taken serious at Hollygarth. EVIDENCE: There have been very few complaints about Hollygarth, but where this has been the case concerns have been dealt with quickly with a view to resolving issues to the satisfaction of all concerned. The manager and staff have an understanding of the role of the Commission for Social Care Inspection in helping to resolve complaints. In respect of the Protection of Vulnerable Adults, the deputy manager and a senior carer have undertaken training in respect of the Department of Health’s ‘No Secrets’ Guidance. It is planned to disseminate this information to staff within the next two months. Again, the manager has an understanding of the process of adult protection referral, and has implemented this when needed. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 13 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 Hollygarth is safe and well-maintained and the décor is homely and comfortable. EVIDENCE: Although not assessed in detail at this Inspection, observation of the home again confirmed that it is well-maintained, homely and comfortable. New bathroom furniture has been provided in the downstairs bathroom. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 14 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 and 29 Staff numbers are appropriate to meet needs, as is the staff mix of skills. EVIDENCE: The home is staffed to levels agreed by the previous registration authority and there has been no reduction of staff. The majority of staff are trained to at least NVQ Level 2, with only one staff member required to start work on Level 2. A dedicated cook is employed, as well as a dedicated cleaner. The recruitment policy of the home states that two references must be provided, along with both a CRB (Criminal Records Bureau) and Pova (Protection of Vulnerable Adults) check. Advice was given to the manager about the latest Department of Health guidance on enabling staff who have provided documentation in respect of the above checks to commence work, as long as they are supervised at all times until clearance is received. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 15 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, 35 and 38 The home is well-managed by an experienced manager, who is supported by a skilled deputy manager. Service users’ financial interests are safeguarded by way of accurate recording and documentation. Health and safety issues are promoted and protected. EVIDENCE: Discussion with both staff and service users and assessment of documentation confirms that the home is well-managed. The Registered Manager is a qualified nurse, who also holds a Post-Graduate Diploma from the University of Teesside covering Management and Health & Safety. The Deputy Manager is in the process of completing the Registered Manager’s Award. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 16 Most service users’ families assist with financial issues, and one resident is covered by a Court of Protection arrangement, which was instigated as a result of concerns expressed by the manager. In respect of the remaining two residents, personal allowance monies retained for safety are recorded by the manager, and receipts for personal items are retained. One of the two Proprietors of the home has now assumed responsibility for auditing health and safety issues. Water temperatures are checked on a weekly basis and recorded so that any necessary adjustments can be made. Fire alarms are also checked on a weekly basis. Gas equipment and supply is serviced on an annual basis, under contract to the Gas Board. A visit from a Fire Officer resulted in a recommendation that all doors must be closed at night and the manager said that this advice is complied with. Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 17 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 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 18 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 OP8 Regulation 17 Requirement Development of Care Plans and Risk Assessments must continue to ensure that these documents can be used to fully inform care staff Timescale for action 31/03/06 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 Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Hollygarth DS0000000069.V258941.R01.S.doc Version 5.1 Page 20 - 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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