CARE HOMES FOR OLDER PEOPLE
Holywell Dene Care Home Holywell Dene Holywell Whitley Bay NE25 0LB Lead Inspector
Jackie Burke Announced 12 July 2005 09:30 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. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Holywell Dene Care Home Address Holywell Dene Holywell Whitley Bay Tyne & Wear NE25 0LB 0191 237 4424 0191 237 4420 holywelldene@highfield-care.com Highfield Care Homes Limited 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) Mrs Heather Laidler CRH 50 Category(ies) of OP - Old Age (50) registration, with number of places Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th January 2005 Brief Description of the Service: Hollywell 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 situated on a sloping site in the village of Hollywell and the main entrance at the front of the building gives access to the middle floor, services and accomodation are also provided on the ground and second floors. The rear of the building overlooks Hollywell Dene and there are pleasant views over the Dene from the sitting rooms located on the first and second floors. Dining rooms are located on each floor and meals are prepared cooked and served on the premises. A passenger lift provides access to all floors. There is a patio located to the side of the building where service users and visitors may sit, garden furniture is available and a gazebo has been erected to afford protection from the weather. Parking is available at the front of the building and ramps at the front door provide access for poeple 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 13 W.C. facilities provided in addition at Hollywell Dene. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is a report of an announced inspection, which took place on Tuesday 12 July 2005. The inspection took five hours and during this time the inspector spoke with nine service users, five visitors, four staff on duty, the acting manager and the administrator. Thirteen service users comments cards were returned as part of this announced inspection process and one relatives/visitors comment card What the service does well: What has improved since the last inspection? What they could do better:
There are currently vacancies for a deputy manager and an activities coordinator, which must be addressed in order to further develop the management team and the range of activities available. The complaints procedure should be reviewed and clear information given to service users regarding complaints and who to speak to. The menu should be reviewed with service users to allow for a variety of options at tea- time in addition to lunch-time. The laundry arrangements should be reviewed as service users have expressed concerns that laundry items go missing.
Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 6 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 are low and a considerable investment must be made to encourage staff to engage in NVQ training in order to work toward achieving the requirement of 50 of qualified staff before the end of 2005. The whistle blowing procedure should be reviewed and staff encouraged to take part in training relating to the protection of vulnerable adults. 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. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 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 Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 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) 3 Service users needs are assessed before moving into Hollywell Dene and identified needs are met by the service. EVIDENCE: Hollywell Dene Care Home works to an admissions policy and assessment documentation is of a good standard. Case files examined during the inspection indicate that the assessment of service users needs is carried out by care managers in relevant local authorities and in addition the Acting Manager also does an individual assessment before admission. Needs identified during assessment are written into a care plan which is developed fro each service users to ensure that identified needs are met. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-10 Service users needs are set out in a plan of care. Health care needs are met in full. Hollywell Dene has a satisfactory policy for dealing with medication. Residents are treated with respect and privacy is safeguarded. EVIDENCE: Four case files were examined during the inspection and the contents were well organised and recorded with information relating to assessment, health, personal and social care needs and care plans clearly identifying 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 needs of individuals is sought from health care professionals and appropriate action taken. The needs of individuals are monitored and reviewed and care plans altered accordingly. There is a medication policy at Hollywell Dene and staff are trained to give out medication. Records reflect that staff are aware of residents rights to privacy and those rights are respected in terms of daily routines regarding meals, bathing preferences and sleep routines. People spoken to during the inspection
Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 10 confirmed that they are given choice as to getting up and going to bed and preferences in sitting areas and daily routines. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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: A range of in house activities are provided at Hollywell Dene which include quizzes, bingo, singing, games, manicures and hairdressing. In addition people who live in the home are encouraged to go out within the local community to the local shop and pub and trips may be organised further afield. One person commented that there was not enough to do at Hollywell Dene if you didn’t like bingo, which she did not and that she would prefer more activities to be offered outside the home. On the day of the inspection many people took advantage of the good weather and sat outside on the patio, people commented positively on how nice it was to be able to sit outside. Many people spoke well of the food at Hollywell Dene and one person said that she could have a cooked breakfast every day if she wanted it and that there was always a choice at dinner time, however the menu at tea time was always sandwiches and she would prefer a choice. Drinks and fresh fruit are available in the lounges at Hollywell Dene and this is to be commended . One lady said that the food was good but a bit stodgy and she also stated that sandwiches
Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 12 for tea was dull and she would prefer some variety in the tea -time options. One person said that he felt he had put weight on since arriving at Hollywell Dene but the food was not what he was used to and he would like to see some variations to the menu. Two people commented on laundry arrangements and said that they had lost items in the laundry system, one family member said that they took laundry home for their relative as they were concerned about items getting lost. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 13 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 &18 There is a complaints policy however it service users indicated that they were unsure who to speak to if they had a complaint. Service users are protected from abuse. EVIDENCE: There is a complaints procedure at Hollywell Dene however Service User’s comments cards returned prior to the inspection suggest that eleven respondents were unsure who to complain to if they were dissatisfied with the service they received. Some service user’s spoken to during the inspection said they would speak to the manager if they had a complaint however not all of those knew how to make a complaint. Three people said that they had no complaint to make. There is a whistle blowing policy at Hollywell Dene and the manager demonstrated her commitment toward training staff in recognising abuse and in the protection of vulnerable adults. A recent allegation within the home has been dealt with appropriately and an action plan developed. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 14 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 & 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 hanging baskets and planting at the front door and to the side of the building. Hand rails 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 Hollywell Dene and sitting rooms and dining rooms are well appointed throughout the building. There is a handy man in post at Hollywell Dene who undertakes maintenance tasks and domestic and laundry staff who ensure that the home is clean and hygienic. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 15 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) 27,29 & 30 People’s needs are met by the numbers and skills of staff People are protected by the recruitment policy and practice The manager is commited toward training staff in the competencies required to do the job. EVIDENCE: There are two vacancies at Hollywell Dene for a deputy manager and an activities coordinator, which are to be advertised in the near future. There are sufficient staff currently in post once those vacancies are filled to fully meet the needs of service users; agency staff are not used at Holywell Dene. Records confirm that Criminal record Bureau checks are undertaken and written references obtained and that the recruitment policy within the home is being met. The acting manager is committed to training and records confirm that mandatory training is up to date however recent staff changes mean that there are too few staff qualified to NVQ level 2 or above and consequently this standard is not met. The acting manager is willing to engage in Registered Manager’s Training and this was recommended at the last unannounced inspection however as yet this has not been arranged. It is a requirement of this inspection that the manager and staff are encouraged to undertake appropriate NVQ training. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 16 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) 33,35 & 38 The home is run in the best interests of service users. Service users financial interests are safeguarded. The health safety and welfare of service user’s and staff are promoted and protected. EVIDENCE: Evidence was provided during the inspection process, which confirmed that the home is run in the best interests of service users. 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. Individual accounts are being set up to ensure that this is undertaken. Health and safety is promoted at Hollywell Dene and records were made available during the inspection process which relate to fire records maintenance contracts & records regarding the lift, hoists, central heating, water temperature records
Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 17 C.O.S.H.H. regulations 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. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 18 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 x 3 x x x 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 2
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x 3 x 3 x x 3 Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 19 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 OP15 OP16 Timescale for action 16 (2) Menu options should be reviewed 1/10/05 (e)(f) (i) with service users and a varied tea time menu provided. 22 (1) (2) The complaints procedure should 1/11/05 be reviewed and service users given clear information on how to make a complaint and who to speak to if they have a complaint. 19 (4) (a) The whistle blowing policy 1/12/05 (5) (a) (c) ahould be reviewed and staff training facilitated to ensure all staff are aware of the protection of vulnerable adults. 18 (1) (a) The registered person must 31/12/05 19 (5) (b) continue to facilitate training to ensure that 50 of staff employed achieve NVQ level 2 18 (1) (c ) The manager should commence 31/12/05 (i) the Registered Managers Award and work toward achieving the management qualification in the specified time. Regulation Requirement 3. OP18 4. OP28 5. OP31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 20 No. 1. Refer to Standard OP12 Good Practice Recommendations The laundry system should be reviewed and measures introduced to prevent personal items of clothing going missing. Holywell Dene Care Home B53-B03 S609 Holywell Dene V227506 120705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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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