Inspection on 03/07/08 for Hollygarth

This inspection was carried out on 3rd July 2008.

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

Hollygarth 06/11/06

Hollygarth 17/02/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Hollygarth 80 Roman Road Linthorpe Middlesbrough TS5 5QE Lead Inspector Val Daly Key Unannounced Inspection 3rd July 2008 10:00 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.V367849.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. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 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.V367849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th November 2006 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 11 older people. 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 nine single rooms, six of which are en suite and one double room, which is en suite. Communal areas consist of a large lounge, which is light and airy and has a view over the garden, and a smaller, second lounge that 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. Information about the homes services and facilities are available on request. Fees in the home are £405 per week. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use this service experience good quality outcomes. This inspection was a key unannounced inspection and was completed by an inspector and a regulation manager in one inspection day. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. A number of records were looked at including assessments of people who use the service and plans of care, staff recruitment records, complaints and maintenance records along with the annual quality assurance assessment. Two people who use the service, two members of staff the manager and deputy manager, were engaged in discussion about living at Hollygarth. The manager had completed an Annual Quality Assurance Assessment prior to the inspection. The AQAA is the services self-assessment of how they think they are meeting the National Minimum Standards. This information is received prior to the inspection and it is then used as part of the inspection process. On the day of the visit the manager and deputy manager provided the information and documentation required. The Commission for Social Care Inspection sent a number of surveys to the home for people who use the service and their relatives to complete. Five were completed and returned. Comments received can be read within the report. This was a positive inspection; people were open and friendly and welcomed discussion about the home. What the service does well: Hollygarth provides a clean, pleasant and well-maintained home for people to live. Staffs work well together as a team to provide the people who use the service with a comfortable and homely environment, offering a good standard of care. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 6 The menu showed that a variety of food is offered with lots of home baking. Alternatives to the main meals are available if people do not like the choices on the menu Comment cards from relatives and people who use the service stated. ‘The meals are excellent, all home cooked food. People are given lots of choice’. ‘It is homely here with all home cooking. Alternatives are always provided if the person doesn’t like something’. What has improved since the last inspection? What they could do better: Whist medication is kept safely, for controlled drugs further secure measures are required. The policy for adult protection needs to be developed further no include ‘No Secrets’ guidance and contacts for reporting suspected abuse. Whilst staff had received training in areas such as Moving and Handling, Health and Safety, COSSH and Infection Control this required updating. At the time of the inspection the manager and deputy manager were in the process of putting a training programme in place and arranging refresher training. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 7 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. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs assessed. EVIDENCE: Care managers carry out assessments prior to a person moving into the home to ensure their needs can be met. The home manager also carries out her own assessment, meeting with the prospective person, either in his or her own home or in hospital. This information was viewed in the files of two people who use the service. A life history of the person is taken, which is very informative and can assist with the social care plan. Relative comment cards stated that they had enough information before deciding if the home was right for their family member. The home does not provide intermediate care. Hollygarth DS0000000069.V367849.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 health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Two care files were examined and they each contained an individual plan of care. The plans were evaluated and reviewed regularly. They were well set out and easy to read. The plans contained a good personal history of the person detailing life events and information about their family. Information was also included following on from the life history on how the person likes to spend their day, which was comprehensive. Key workers also complete a monthly review, reporting on the physical and mental well being of the person. Healthcare professional visits were recorded, which showed that the person’s health care needs were being met. Risk assessments were in place where needed, for one person, risk of falling or slipping and the risk of sunburn. The Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 11 plans of care are agreed and signed by either the person who uses the service or their relative. Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. The policy for drug errors requires further development and detail. For people wishing to manage their own medication a risk assessment and management process was in place. Staffs who administer medication had received safe handling of medication training. Whist medication is kept safely, for controlled drugs further secure measures are required. Comment cards from relatives and people who use the service stated ‘I am very pleased with all aspects of care provided and availability of staff when needed’, ‘Care staff are nice and helpful’, Care staff do their job well with a sense of humour’ ‘Staff are friendly and caring’. A comment card from a health professional stated ‘Care staff work very well with community services. They act positively to any treatment or care plan that community nurses initiates. They are open to any suggestions to improve client care and are quick to respond should a resident require GP or community service input’. Hollygarth DS0000000069.V367849.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. People who use services are able to make choices about their lifestyle. A variety of food is offered. EVIDENCE: People who use the service enjoy a variety of activities on a daily basis. A volunteer visits the home twice weekly, plays the piano for sing a longs and has reminiscence session. Other activities include cards, dominoes and movement to music. People also enjoy watching a film whilst having a drink and some nibbles. Following an activity a written evaluation is completed, stating who participated and if they enjoyed it. Communion takes place in the home regularly. People who use the service said their relatives were able to visit at any time and were always made to feel welcome. The menu showed that a variety of food is offered with lots of home baking. Alternatives to the main meals are available if people do not like the choices on the menu. Staffs ask people what they would like prior to the meal being served. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 13 The majority of people in the home eat their meals in the dining area but they are able to eat in their rooms if they wish. Comment cards from relatives and people who use the service stated. ‘The meals are excellent, all home cooked food. People are given lots of choice’. ‘It is homely here with all home cooking. Alternatives are always provided if the person doesn’t like something’. Hollygarth DS0000000069.V367849.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 good. This judgement has been made using available evidence including a visit to this service. People know how to complain and the home has an appropriate procedure in place. Staff know the procedure to follow in the case of suspected abuse however training in adult protection is required for some of the staff. This will keep the people who use the service safeguarded. EVIDENCE: People using the service said that they would be comfortable speaking to a member of staff if they had any concerns. Comment cards from relatives and people who use the service stated ‘a member of staff explained how to make a complaint but I have never needed to’, I would go to the manager if I had a complaint’. The home has a complaints policy and procedure in place. There had not been any complaints made to the home since the previous inspection. The home has a whistle blowing policy and an adult protection policy in place. However this needs to be developed further no include ‘No Secrets’ guidance and contacts for reporting suspected abuse. During interviews with staff they were able to describe the procedure to follow in the case of suspected abuse. However training in adult protection is required for some staff. Comment cards from people who use the service and their relatives stated ‘I know how to make a complaint but I have never needed to’, I would go to the manager if I had a complaint’. Hollygarth DS0000000069.V367849.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. Hollygarth is comfortable, homely and well maintained EVIDENCE: A tour of the home was carried out. People’s bedrooms contained personal possessions and were comfortable and homely. The home was very clean and tidy without any odours. Since the previous inspection refurbishment and re decoration had been carried out throughout the home. The provider said she planned to convert a bathroom into a shower room, which would enhance the facilities for the people who use the service. A comment card from a person who uses the service stated ‘The home is spotless, well furnished and decorated’. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Vetting and recruitment practices are in place. Staffs require further training to ensure the people who use the service are safeguarded. EVIDENCE: The home has a rota in place, which is flexible for the needs of the people who use the service. There is a policy and procedure in place for the recruitment of staff. Staff records showed that in the main the required information, references and CRB checks were in place prior to staff commencing work in the home. However in some of the files of staff that had been employed for some time two references had not always been obtained. The deputy manager said she was in the process of checking all files and ensuring correct information was in place. The manager said that whilst they had not been using the Skills for Care Induction Programme this was now in place for any new starters. Whilst staff had received training in areas such as Moving and Handling, Health and Safety, COSSH and Infection Control this required updating. At the time of the inspection the manager and deputy manager were in the process of putting a training programme in place. Staff had recently received training in Fire Safety and training in Managing Aggression and Moving and Handling had been arranged for August 2008. There are ten carers employed in the home, five Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 17 had completed NVQ level 2 or above and a further two had commenced the course. The deputy manager advised she was to enrol on a course for the registered managers award. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home regularly reviews aspects of its performance through a good programme of self-review, which include seeking the views of people who use the service and relatives. EVIDENCE: The manager is qualified and competent to run the home. At the time of the inspection the manager and deputy manager were in the process of completing and sending out questionnaires for the people who use the service and their relatives. The manager said this is done annually, however changes and further development had been carried out for this year. Formal meetings for people who use the service are not held, however one to one or small group Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 19 discussions take place regularly. Meetings for staff are held; the manager said she intended to hold these more frequently. The home does not hold monies on behalf of the people who use the service. When the hairdresser or chiropodist has attended to a person the manager sends an invoice to their relative or representative. Maintenance records were examined which showed that all testing of equipment was up to date. Documentation showed that water temperatures are taken weekly and was within the recommended range. The home has health and safety policies and procedures in place. The manager said she was in the process of arranging refresher training for the staff. Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 separate metal cupboard, attached to a permanent wall with deadlocking is required for the safekeeping of controlled drugs. Training in adult protection is required for some of the staff. This will keep the people who use the service safeguarded. There must be two written references in place for each member of staff employed in the home. This is required to safeguard the people who use the service. Refresher training for staff is required in Moving and Handling, COSSH and Infection Control. This is required to safeguard the people who use the service. Refresher training for staff is required in Health and Safety. This is required to safeguard the people who use the service. Timescale for action 30/10/08 2. OP18 18 (c) 30/08/08 3. OP29 19 (4) 30/08/08 4. OP30 18 (c) 30/09/08 5. OP38 18 (c) 30/09/08 Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 22 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 OP18 Good Practice Recommendations The adult protection policy needs to be developed further no include ‘No Secrets’ guidance and contacts for reporting suspected abuse Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Hollygarth DS0000000069.V367849.R01.S.doc Version 5.2 Page 24 - 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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