Inspection on 06/11/06 for Hollygarth

This inspection was carried out on 6th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 03/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hollygarth 80 Roman Road Linthorpe Middlesbrough TS5 5QE Lead Inspector Neil McKenzie Key Unannounced Inspection 10:30 6 and 13th November 2006 th 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.V318051.R02.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.V318051.R02.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.V318051.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th February 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 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.V318051.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The inspection lasted for 8 hours and this included 2 visits to the home. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards for Care Homes. During the visits the inspector spoke to 2 residents and 3 staff to find out what their views were about living and working at Hollygarth. The inspector also spent time speaking to the manager and owner of the home. The inspector spent some more time watching how staff and residents are with each other. A tour of the home took place and records looked at included staff recruitment and training, resident care plans and how the home handles money and medication. There was also questionnaire’s sent to the home, residents and relatives and these were looked at to help decide how good a job the home does in meeting the National Minimum Standards. At the time of the inspection the minimum and maximum cost for a bed was £338.00 per week. There were additional costs for hairdressing, chiropody and personal items. What the service does well: What has improved since the last inspection? Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 6 It was agreed at the last inspection, work should continue to develop both Care Plans and Risk Assessments. Training days were set aside to ensure staff used care plans and risk assessments. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The manager ensures that needs are assessed prior to admission to the home. EVIDENCE: A resident interviewed confirmed that before deciding to move into Hollygarth they had visited other homes as well as Hollygarth and received information on the home. The home provides an easy to read pamphlet with photographs and clear statement about what the home can provide. Resident files sampled had such a pamphlet available. As the resident stated, ‘ I have been in for three days, I visited 5 other homes, and I thought this was more homely’ Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 9 As well as these visits the manager and team leader of the home confirmed that they are aware of the need to ensure that full and comprehensive assessment of need takes place, prior to admission to the home. To help facilitate this, a pre-admission assessment form has been devised, information from which can then be transferred into a care plan. The files looked at had completed needs assessments available. In addition those residents who had not referred themselves to the home had pre-assessment of needs completed by an external qualified professional. Hollygarth DS0000000069.V318051.R02.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): Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. Care plans have recently been developed to ensure both social and care needs can be detailed and reviewed on a regular basis. However, not all care plans are complete. Residents are protected by the home’s policy and procedure for handling medication but some are not practised. Residents’ spoke highly of staff. EVIDENCE: Three resident files were looked at and discussed with the Team Leader and Manager. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 11 New care plan formats have been introduced to ensure both social and care needs can be detailed and reviewed but in resident files looked at some of these were incomplete. This was raised and discussed with the manager and team leader who acknowledged that staff were not using the new care plan and risk assessment format as a working tool. The reason given that staff find new formats difficult to use and understand despite training. The home is now reviewing those formats. During the inspection the home’s policy and procedures and arrangements for receiving, storing, administering, recording and disposing resident’s medication were observed, examined and discussed in depth with the senior staff member responsible to administer medication that day. At the time of the inspection visit, medication was seen to be correctly stored with accurate records for disposal. However, records must offer an explanation when prescribed medication is not handed to a resident. Separate records for controlled drugs must also be witnessed and counter signed when administered. Staff interviewed stated that only qualified senior staff handled medication. Staff members who handle medication attend an external training course and receive a certificate on completion. These certificates are kept in staff files. Individual residents’ medication record sheets did not contain photographs of the person to help ensure that residents receive the correct medication. At the time of the inspection there were no residents who were administering their own medication. Observation during the inspection saw staff gently consulting and prompting residents when handling medication. The residents’ who spoke to the inspector stated that staff treated them with respect and dignity. Comments made by residents included:‘Satisfied with staff, very good, lovely here’ ‘Very genuinely homely, they do look after you here compared to other homes I have lived in’. Hollygarth DS0000000069.V318051.R02.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): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Residents living at Hollygarth say they are satisfied with their lives at the home. EVIDENCE: Residents are involved in choosing an activity programme that is recorded in their care plan. Motivation sessions are available on a regular basis, provided by an independent company. In addition there are informal outings from the home, which can be shopping trips or calling at cafes for coffee. This includes a planned Christmas concert. One resident interviewed spoke of his regular trips to church to practice Holy Communion. At the time of the inspection a visiting relative played the piano and residents joined in a relaxed and informal singsong. The motivation session also brought a lot of laughter and fun. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 13 Residents interviewed confirmed that family members visit them on a regular basis. One relative returned a survey and stated that staff makes them feel welcome in the home and involve them in matters affecting their relatives care. Food is said to be good and the meal served at the time of the inspection was tasty and wholesome. One resident stated ‘food, good food here’. Hollygarth DS0000000069.V318051.R02.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): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Residents are protected by a complaints procedure and a policy and procedure on adult protection and prevention of abuse. EVIDENCE: There have been no complaints or protection allegations since the last inspection. Complaints are recorded in a complaints file and are signed off by the manager. The team leader has recently undertaken training in respect of Protection of Vulnerable Adults. It is planned to disseminate the information from this course to staff. The manager has an understanding of the process of adult protection referral. Hollygarth DS0000000069.V318051.R02.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): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. On the whole Hollygarth is well maintained and the décor is homely and comfortable. EVIDENCE: The home provides a clean, comfortable and homely atmosphere. Internal décor and furniture are of a good standard and residents’ benefit from a conservatory overlooking the garden and a pleasant patio area to the rear of the home. Rooms seen at the time of the inspection were personalised with resident furniture, photographs and pictures. Resident comments included:‘Very good, it is homely here’ ‘See it as my home, very genuinely homely, they do look after you’. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 16 At the time of the inspection the garden fence next to the main path was partially blown down and a potential hazard for residents and visitors. When raised with the manager the manager said repair was being discussed with the neighbours although no timescale had been agreed. The main path in the garden is also uneven and a visitor commented this is could cause someone to fall. Currently the kitchen door is not locked when not used by staff and this could also be a potential hazard for residents. The manager agreed to review this practice by implementing a risk assessment. A recent fire inspection by the fire service and an environmental health officer made recommendations that the home is expected to action. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home is staffed to levels agreed by previous registration authority and residents are protected by the homes recruitment practices. EVIDENCE: An audit of the duty rota was carried out. At the time of the inspection there were 10 residents living at the home. There was 1 senior carer and 1-care assistant during the morning shift. There was 1 senior carer and 1-care assistant during the afternoon and evening shift. Supporting the day shift and residents in the home a dedicated cook, a dedicated domestic and the registered manager. There is 1 carer on the rota for the night shift and this person is supported by on call back up. Day and night staffs have additional responsibility for laundry on behalf of residents and serving the evening tea. The manager has promoted National Vocational Qualification (NVQ) Level 2 and 3 in Care training to staff to offer residents’ safe and competent staff. At the time of the inspection 50 of care staff had an NVQ level 2 or 3 in Care. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 18 The recruitment files of 4 staff were looked at. Staff more recently employed had records of application forms and references in their files. Evidence was in place to show that Criminal Records Bureau disclosures at Enhanced level had been received for all staff members working in the home. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. An experienced manager who is in the process of inducting 2 team leaders to support her in this role manages the home. Staffs require more regular supervision. Resident financial interests are recorded and documented. Health and safety issues should be enhanced by up to date mandatory training requirements for staff. EVIDENCE: The registered manager is a qualified nurse, who also has a Post-Graduate Diploma covering Management and health and safety. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 20 Since the last inspection the deputy manager has left and the manager is in the process of inducting 2 team leaders to support her in her role as manager. A team leader interviewed stated that she is in the process of starting the Registered Manager’s Award. A Sample of staff files indicate that staff require more formal supervision, at least 6 times a year, to support them in developing their work practices. Staff interviewed stated the home has regular meetings with residents to discuss matters important to residents. However, these meetings are currently not documented. The home has had in the past annual resident and relative surveys to ensure the home is run in the best interests of residents. A sample of resident personal allowances was looked at with the manager. All residents’ families assist with financial issues and 2 residents are covered by Court protection arrangements. The manager in individual books with copies of receipts documents resident transactions for purchase of personal items and hairdressing. Details of health and safety were made available through the pre-inspection questionnaire and tour of the premises. These records were recorded as up to date with relevant certificates, for example gas safety, available on request. The registered manager should review mandatory training requirements of staff to ensure the health and safety of residents and staff are promoted within the home. For example updated training in First Aid and Food Hygiene. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 22 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 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 The registered manager must continue to demonstrate the home’s capacity to meet assessed needs of individuals admitted to the home. The registered person must ensure that staffs adhere to procedures for the recording and handling of medication. The registered manager must ensure staffs have up to date training with regard to health and safety. Timescale for action 31/12/06 2. OP4 4 13/11/06 3. OP9 13 13/11/06 4. OP38 18 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 23 No. 1. Refer to Standard OP9 Good Practice Recommendations Individual residents’ medication record sheets should contain photographs of the person to help ensure that residents receive the correct medication. Care staff should receive formal supervision on all aspects of practice by the manager at least 6 times a year. Pathways and fences should be maintained to promote a safe environment A recent fire inspection by the fire service made a number of recommendations that the home should action. 2. 3. 4. OP36 OP38 OP19 Hollygarth DS0000000069.V318051.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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.V318051.R02.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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