CARE HOMES FOR OLDER PEOPLE
Holywell Dene Care Home Holywell Dene Holywell Whitley Bay Tyne & Wear NE25 OLB Lead Inspector
Jackie Burke Unannounced Inspection 10th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000000609.V259180.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000000609.V259180.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Holywell Dene Care Home Address Holywell Dene Holywell Whitley Bay Tyne & Wear NE25 OLB 0191 - 2374424 0191 237 4420 holywelldene@highfield-care.com 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) Southern Cross Care Homes Limited Mrs Heather Laidler Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places DS0000000609.V259180.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th July 2005 Brief Description of the Service: Holywell Dene Care Home is a purpose built facility, which provides residential care for up to 50 people over the age of 65years. The building is located on a sloping site in the village of Holywell and the main entrance at the front of the building gives access to the middle floor, services and accommodation are also provided on the ground and second floors. The rear of the building overlooks Holywell Dene and there are pleasant views over the Dene from the sitting rooms located on the first and second floors. Separate dining rooms are on each floor and meals are prepared cooked and served on the premises. A passenger lift provides access to all floors. There is a large patio to the side of the building where service users and visitors may sit, garden furniture is available and a gazebo is available during summer months. Parking is available to the rear of the building and ramps at the front door provide access for people with mobility difficulties. Holywell Dene provides 46 single bedrooms, and 2 double rooms 35 of which have en-suite facilities. There are 6 bathrooms providing assisted bathing and an additional shower room. There are a further 13 W.C. facilities provided at Holywell Dene. DS0000000609.V259180.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is a report of an unannounced inspection, which took place on Tuesday 10 January 2006. The inspection took five hours and the inspector spoke to nine service users, three visitors, six staff on duty and the manager. What the service does well:
Holywell Dene provides a warm homely welcome for residents and visitors. People living in the home are encouraged to have visitors and to go out in the local community; there are a range of in house activities provided and the home shares access to a mini bus to enable trips to take place on a rota basis. Observations on the day suggest that staff are aware of the needs of their service users and respond with care and warmth to those needs. Records are well maintained and up to date. The manager has worked hard since coming into post to develop the strengths of her team and to encourage participation in training. Staff spoke well of the manager and team spirit within the home. There have been five complaints made in the past year, which have been dealt with appropriately; discussion took place with the manager regarding the recording of complaints. A number of staff were unwell on the day of inspection however those who were at work shared the workload and worked well together to ensure that the needs of residents were met. Three visitors spoken to were very positive about the home and the staff. One person said that she was happy with the level of care provided and that she felt confident that the staff would do what was needed for her relative. A professional said that she found Holywell Dene responded well to the needs of service users and were accommodating in providing short term placements and respite care. People spoken to during the inspection say that the staff work very hard and that they will “help out with anything you need”. One lady said that everyone had been very kind since she had come in to the home. The home responds well to the needs of respite users and records relating to a recent admission were accurate and well maintained. DS0000000609.V259180.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
One visitor commented that private fees should include costs of bedding and curtains within the rooms as his family had been asked to provide soft furnishings. This issue was discussed with the manager who stated that families are not asked to provide curtains and bedding; soft furnishings are provided by the home however some people choose to provide their own bed covers, curtains are provided by the company as they must be fire retardant to comply with fire safety regulations. The manager is committed to training and should have access to the Registered Managers Award to further develop her confidence and management skills. The numbers of staff who have achieved NVQ level 2 continue to fall below the 50 requirement and staff should be further encouraged to engage in NVQ training in order to work toward achieving the requirement of 50 of qualified staff before the end of 2006.
DS0000000609.V259180.R01.S.doc Version 5.0 Page 7 There is a complaints policy in place at the home and the procedure has been followed in relation to complaints made over the past year however the manager has not cross referenced records to the complaints file. Records have been made and sensitive information stored in a locked cabinet; the manager was advised to log all complaints in the complaints file and to cross reference this to supporting documentation and action plans. The manager has developed an action plan for the home, which includes improvements in the training programme and the provision of formal supervision for staff. Supervision is provided on an informal basis however formal written records must be kept. 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. DS0000000609.V259180.R01.S.doc Version 5.0 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 DS0000000609.V259180.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users needs are assessed before moving into Holywell Dene and identified needs are met by the service. EVIDENCE: Holywell Dene Care Home works to an admissions policy and assessment documentation is of a good standard. Case files examined during the inspection indicate that care managers seeking placement carry out the assessment of service users needs; in addition the Manager does an individual assessment before admission. Needs identified during assessment are written into a care plan for each service user which is then used to provide care on a day-to-day basis. DS0000000609.V259180.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 Service users needs are set out in a plan of care. Health care needs are met in full. Holywell Dene has a satisfactory policy for dealing with medication. Residents are treated with respect and privacy is safeguarded. EVIDENCE: Three case files were examined during the inspection and the contents were well organised and recorded with information relating to assessment, health, and personal and social care needs. Care plans clearly identify how those needs will be met. Files contain risk assessments and action plans to deal with identified risks. Sensitive information is dealt with confidentially and daily records reflect an awareness of service users needs. Advice on the specific health care needs of individuals is sought from relevant professionals and appointments recorded and appropriate action taken. The needs of individuals is monitored and reviewed and care plans altered accordingly.
DS0000000609.V259180.R01.S.doc Version 5.0 Page 11 There is a medication policy at Holywell Dene and staff are trained, to give out medication. Arrangements have been made to change pharmacy provision from a local chemist to Boots pharmacist in line with Southern Cross policy and training information has been provided and training will be updated to staff when this is in place. DS0000000609.V259180.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Needs are identified during assessment and activities and routines are developed accordingly. Links with families, friends and the community are encouraged. People are encouraged to exercise choice in their lives. People are provided with a balanced diet and meal routines are provided flexibly wherever possible. EVIDENCE: The vacancy for the activities coordinator has now been filled and there are a range of in house activities are provided in the home which include quizzes, bingo, singing, games, nail care and the hairdresser visits weekly. An entertainer attended the Christmas party and a clothing party and a make up party was organised before Christmas. People who live in Holywell Dene are encouraged to go out within the local community to the local shop and pub and trips may be organised further afield. Southern Cross provides a mini bus, which is shared by a number of homes in the area that share access on a rota basis. The bus was used before Christmas to enable people to go shopping and to see the Christmas lights. Some people
DS0000000609.V259180.R01.S.doc Version 5.0 Page 13 commented that they liked to sit together in the sitting room and to watch what was going on during the day. One lady said that she could join in with activities but wasn’t fussed and that she liked her own company. The management team have undertaken a client satisfaction survey to support residents to exercise choice and to have a say in decision making within the home. Issues raised within the survey have been identified and developed as part of the action plan for the home. Residents meetings are organised but are poorly attended and the manager hopes to improve access and to encourage residents to become more involved. There is a four week menu available at Holywell Dene one visitor spoken to commented that he felt some menu options were inappropriate for older people who would not be accustomed to foods like chicken nuggets and fish fingers; in his opinion foods which people would have cooked themselves at home would be more familiar to people living in the home. The manager has attempted to consult with residents regarding food choices and the menu via residents meetings but the last meeting was poorly attended and she felt that people were apathetic on this issue. The kitchen was understaffed on the day of inspection due to ill health and the cook adapted the menu to allow for this, scotch pie, chips gravy and peas were offered as well as a salad option. Staff worked together to ensure that meals and drinks were provided to residents. The kitchen caters for special dietary requirements and currently provides suitable food for a number of people with diabetes in the home and a soft diet for one person with swallowing difficulties. Drinks and fresh fruit are available on request in the dining rooms. One lady said that the food was very good and the only concern that she had was that she would gain weight as teas have improved and she gets a lot to eat at lunchtime. The laundry was inspected and there is a system in place to deal with lost property and people are encouraged to label clothing to prevent losses occurring. Named baskets are used to track clothing items, which come into the laundry. Sluice facilities are available and industrial machines used to ensure that laundry is dealt with at an appropriate temperature to maintain hygiene and to prevent cross infection. DS0000000609.V259180.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is a complaints policy in place. Service users are protected from abuse. EVIDENCE: There is a complaints procedure at Holywell Dene, which has been reviewed since the last inspection. Information about the procedure is displayed with key worker information in each bedroom and people spoken during the inspection were clear as to how they would make a complaint and who to. Complaints are recorded appropriately and action taken which complies with the policy in the home. Discussion took place between the manager and inspector relating to the recording and storage of sensitive information and the manager was advised to record all complaints however sensitive within the complaints file and to cross reference supporting documentation and action plans to complaints. There is a whistle blowing policy at Holywell Dene and the manager commented that she felt staff had learned a lot about recognising abuse and the protection of vulnerable adults within the home. The manager is keen to pursue further training and has built the protection of vulnerable adults into her induction-training programme for new staff. DS0000000609.V259180.R01.S.doc Version 5.0 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 the following standard(s): 19 & 26 Service users live in a safe, well - maintained environment The home is clean, pleasant and hygienic. EVIDENCE: The entrance to the home is attractive and well maintained with CCTV covering the entrance hall for security purposes. Handrails and a ramp ensure safe access to the building and the foyer is well lit and attractively presented, this is evident throughout the building. There is a good standard of décor and furnishing in Holywell Dene and sitting rooms and dining rooms are well appointed throughout the building. There is a handy man in post at the home who takes responsibility for maintenance tasks and domestic and laundry staff who ensure that the home is clean and hygienic. DS0000000609.V259180.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 -30 The numbers and skills of staff meet people’s needs Service users are in safe hands. People are protected by the recruitment policy and practice The manager is committed toward training staff in the competencies required to do the job. EVIDENCE: Staff vacancies have been filled since the last inspection and there are sufficient staff in post meet the needs of service users; agency staff are not used at Holywell Dene. There are twenty four care staff working within Holywell Dene, three staff are qualified to NVQ level 2 and one staff member is awaiting her award, there are a further six staff members for whom NVQ training has begun. The manager hopes to begin working toward her Registered Managers Award as soon as possible. It is a requirement of this inspection that the manager and staff are encouraged and supported to undertake appropriate NVQ training. Records confirm that Criminal Record Bureau checks are undertaken and written references obtained. There is a recruitment policy within the organisation, which is being met by the home. DS0000000609.V259180.R01.S.doc Version 5.0 Page 17 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): 31,33,35, 36 & 38 The home is run and managed by a person who is fit to be in charge, of good character and able to discharge her responsibilities fully. The home is run in the best interests of service users. Service users financial interests are safeguarded. Staff supervision should be improved. The health safety and welfare of service user’s and staff are promoted and protected. EVIDENCE: The manager has worked within the care sector for some considerable time and has experience in day care, domiciliary care and in residential care. She has worked in Holywell Dene since 2001 and has covered a range of duties within the home prior to becoming manager. She has completed the
DS0000000609.V259180.R01.S.doc Version 5.0 Page 18 assessment process with CSCI to be judged a fit person to mange the home and demonstrates insight and skills in line with her duties as manager. Heather Laidler is keen to pursue the Registered Mangers Award and hopes to begin the course as soon as possible; it is an outstanding requirement from the last inspection that this training be provided. Evidence was provided during the inspection process, which confirmed that the home is run in the best interests of service users. Residents meetings are organised on a regular basis although the manager expressed concern that it was difficult to engage service users and families in the consultation process. The financial interests of people living at Holywell Dene are safeguarded and records and receipts are maintained to ensure that finances are dealt with appropriately. Staff supervision is provided however should be formally organised and supervision records kept, this has been built into the action plan for the home and should be monitored at the next inspection. Health and safety is promoted at Holywell Dene and records were made available during the inspection process, which confirm this. The home has recently undergone an independent audit and targets were satisfactorily met, records will be forwarded to CSCI to support this in due course. Training records confirm that induction training is undertaken with all new staff and that mandatory training covers aspects of health and safety including food hygiene, moving and handling, and fire training. The manager has also incorporated POVA training and sensory deprivation training into the induction process for new staff. DS0000000609.V259180.R01.S.doc Version 5.0 Page 19 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 3 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 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 DS0000000609.V259180.R01.S.doc Version 5.0 Page 20 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 OP28 Regulation 18(1)a 19(5)b 18(1)( c ) i Requirement The registered person must continue to facilitate training to ensure that 50 of staff employed achieve NVQ level 2 The manager should commence the Registered Managers Award and work toward achieving the management qualification in the specified time. The manager should ensure that formal supervision is provided to staff and records kept. Timescale for action 01/07/06 2. OP31 01/07/06 3 OP36 18(2) 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP15 OP16 Good Practice Recommendations Service users should continue to be consulted regarding meals in the home and menu options should be reviewed on an ongoing basis. Amendments should be made to complaints recording system to ensure that records correspond. DS0000000609.V259180.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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