Inspection on 26/04/05 for Holmfield Court

This inspection was carried out on 26th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holmfield Court 08/08/07

Holmfield Court 30/08/06

Holmfield Court 28/10/05

Holmfield Court 16/12/04

Holmfield Court 09/07/04

Holmfield Court 26/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Holmfield Court 58 Devonshire Avenue Leeds West Yorkshire LS8 1AY Lead Inspector Valerie Francis Unannounced 26 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holmfield Court Address 58 Devonshire Avenue Leeds LS8 1AY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2664610 0113 2665118 Wharfedale Care Ltd Mrs C Peel Care home 25 Category(ies) of Old age (25) Dementia - over 65 (4) registration, with number of places Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/12/04 Brief Description of the Service: Holmfield Court is a detached property located in Roundhay on the outskirts of Leeds. Car parking facilities are available at the front of the property. It is in easy access to local shops and recreational facilities, which some service users use independently. The nearby park and garden are used for trips out. Wharfedale Care Limited is the registered provider; Mrs Peel is the registered manager for the home. The home is registered as a care home for up to 25 older people. The accommodation consists of 21 single rooms 19 of which have en suite facilities, and two double rooms with en suite. There is a large communal lounge, a large dining room, and a central kitchen. There are communal bathrooms, showers and eight communal toilets. The building has had several adaptations; service users accommodation is mainly on two floors with one bedroom on the ground floor with the lounge and dining room, laundry and kitchen. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection over a day, which was unannounced, which started at 11am and completed at 5.45pm. On the arrival to the home the inspector met the person in charge, the manager was not at the home, she however joined the inspector and facilitated in the inspection process. Comment card were given to the manager for her feedback on the way in which the inspection was carried out. Comment cards for both residents and visitors and the new CSCI service users information leaflets were also left. During this time residents’ records and care plans were assessed, observation was made of staff interaction with residents and their relatives. A mealtime was observed although this standard was not audited. Residents, their visitors and staff were spoken with. What the service does well: What has improved since the last inspection? The environment has improved with the recent replacement and redecoration of the dining room. Care assessment is more comprehensive and enables better care planning. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 standard(s) 2,3,4and 5. The home provides prospective residents with information that would give them enough information to make a decision about the care they can expect to receive. EVIDENCE: Funded resident have a copy of their agreement of care with the home. A statement of terms and conditions, which outlines the service provision, and expectations, is given to all residents. Those people who pay their own fees are given in addition a contract agreement of their rights and responsibilities between them and the home. An assessment is made of all prospective residents, to ensure that the home can meet the needs of the individual. Visits can be made to the home before making a decision to live there, to see if they like the building and to make sure that it is a place their care needs would be met. Each resident or their relatives is given a copy of home’s terms and conditions; some have made a decision to keep their copies which was seen on their files Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 9 whilst other are with families. Relatives said they have copies of the agreement and terms and conditions. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9,10 and 11. The health and personal care received by residents is based on dignity, privacy, rights, choice, and independence and fulfilment. Each person has a care plan, which identifies his or her specific care needs. Self-medication is encouraged for residents who are capable to do this. Safe handling of medication is promoted. EVIDENCE: A care plan for each resident is produced from the pre admission assessment, care plan assessment, from residents, their relatives and from Core assessments, to make sure that all the care needs are identified and a care plan put in place. Three care plan files were inspected. However those plans that are in place did not address all of the areas identified in the assessment so that all of the resident care needs will be met. During discussion with staff it was obvious that they were following residents care plans. During discussion with the manager it was indicated that if a resident needed any specialist equipment this would be provided and staff would be made aware, and that this would be documented in the individual care plan. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 11 The night care plans were clear about what to do to meet the individual care needs during the night. A care plan for the last wishes was in place. It was evident from residents care plans that consultation is carried out with the district nurse on pressure area care; pressure relieving equipment is used for those residents at risk. Each resident has a care plan agreement that is signed by them a relative or someone who has an input in their care. A record is kept on individual files of all visits are made by GP’s, District nurses and other health care professionals. All but the latest employed care staff have had accredited training on safe handling of medication. The record of administration of medication was well recorded. Discussion with individual residents and groups there said they were happy with the care provided, they said staff were kind friendly and respectful, one person said “if they were not, I would tell them so.” Visiting relatives said they were involved in the care planning process and they are always told of any changes. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 standard(s) 12 All efforts are made by staff to encourage residents to take part in recreational social activities in and outside the home. EVIDENCE: All residents social care is identified in their care plan, which outline their past life . It is acknowledged that not all residents would take part in activities, but an effort is made for them to enjoy at least one activity a week. On the day of the inspection the hairdresser, was working in the home. It was obvious that each individual time spent with the hairdresser is used as a personal “pamper” time and a time to engage the individual in meaningful conversation on a one to one basis. Staff offer activities such as bingo, knitting and manicure. One of the senior carers had started a knitting circle, though not all residents would like to do crocheting or embroidery. For those who could not do so, an alternative recreational hobby was discussed with them. A variety of other activities has been arranged with residents e.g. exercises, painting and sing along which involved staff and outside entertainers coming into the home. Although there is a television in the large sitting area the staff said in the main the room is used by residents to talk to each other or to sit quietly, reading news papers, or group activities. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 13 Some residents take the opportunity to spend their time in their room reading, watching television, receiving their visitors or generally sitting quietly. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 standard(s) 16 and 18. Residents and their visitors are comfortable with making any complaint they may have and to give constructive suggestions and comments. Protection of residents is very important to both the manager and her staff. EVIDENCE: From the discussion with residents and their visitors they said if they had any complaints they would go the person in charge, but felt that they could discuss any matter of concerns with Mrs Peel. They were confident that any concerns or complaints would be dealt with. The complaints procedure is displayed on the notice board. The home has a good Adult Protection Policy and Procedure, which is supported by the local authority Social Services Adult Protection Procedure and No Secrets document. Staff had had up to date training on Adult Protection, during discussion with staff it was evident that they were fully aware of the procedure of what to do in the event of an alleged abuse. From the discussion with senior care workers they said they were confident what to do and who to contact if in the absence of the registered manager there was an allegation of an abuse. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26. The home is situated in an area that has a variety of recreational facilities. The building is well maintained. EVIDENCE: The location of the home provides residents with shopping and recreational community facilities, which can be used by those who are able to go out independently. The local park is used for short trips out to the butterfly, bird, flower garden and the café, which is used for drinks and snacks whilst they are out. There is a maintenance programme for repairing, replacement and redecoration throughout the building. Since the last inspection the manager has replaced the furnishing in the dining room i.e. chairs and tables. The side tables in the communal sitting room have been replaced as recommended at previous inspection. The windows and external woodwork to the building were in the process of being repainted. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 16 It was obvious that the staff pride themselves in keeping the home clean and free from any malodour. All areas seen were clean and tidy, to a good standard. Staff had attended infection control training and is supported with the home’s infection control policies and procedures. Risk assessments are made of the building and are reviewed yearly. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Staffs have been trained to meet the care needs of residents, and deliver care in a friendly and supported environment. EVIDENCE: The staff team consists of long standing staff that have been at the home for a considerable amount of time. Comment cards received from relatives and visitors said that staffing numbers during the day are not enough to meet the care needs of their relatives or friends. During discussion with the manager regarding staffing numbers she said that the dependency level is looked at and if there was a need to increase the staffing numbers this would be done. All new staff employed have completed an application form and have a CRB check with two references taken. A copy of the job description, GSCC code of conduct and terms and conditions of employment is given. All staff receive induction, the manager said foundation training is being looked into for all, with ongoing training on specialist care and NVQ training. Staff confirmed that they receive regular training that helps them in meeting the needs of residents and for their personal development. During discussion with Mrs Peel it was evident that all areas are explored to ensure that staff have the opportunity to attend training courses that would help them to care for residents. Residents were complementary about the staff and they way in which they looked after them. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 18 Staff were observed as being friendly, enabling and supportive without being overly friendly. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38. There are systems in place to ensure residents’ health and safety. EVIDENCE: All staff have had in house Health and Safety training and the manager said she was looking at comprehensive training from an out side agency. Risk assessments have been carried out on the premise, which is reviewed annually. Staff have been made aware that any other identified risks must be reported to the manager, who would carry out a risk assessment with an action plan how this would be managed. The home has had a recent fire safety inspection carried out by the West Yorkshire Fire Service. Staff have access to policies and procedures on Health and Safety and fire safety. All electrical equipment has been safety tested for which a record is kept. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 20 Fire drills are carried out at least twice a Year with weekly fire alarm test. All moving and handling equipment is routinely checked by the manager or by out side engineers. Records of accidents and incidents were assessed there were copies of all notifications made to the CSCI area office regarding incidents and accidents that had affected the health and well being of residents. Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x 3 3 Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 7 28 Regulation 15 18 Requirement care plan must have identfied needs. previous timescale un met 50 of care staff must have NVQ qulification Timescale for action 30th June 2005 31st December 2005 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 Good Practice Recommendations Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1 HP 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 Holmfield Court J52 S1466 Holmfield Court V185305 Stage 4.doc Version 1.30 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. 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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