Inspection on 30/08/06 for Holywell Dene Care Home

This inspection was carried out on 30th August 2006.

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

Holywell Dene Care Home 21/09/09

Holywell Dene Care Home 30/10/08

Holywell Dene Care Home 02/11/07

Holywell Dene Care Home 10/01/06

Holywell Dene Care Home 12/07/05

Holywell Dene Care Home 18/01/05

Holywell Dene Care Home 20/07/04

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 Holywell Dene Care Home Holywell Dene Holywell Whitley Bay Tyne & Wear NE25 0LB Lead Inspector Jackie Burke Key Unannounced Inspection 30th August 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 Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holywell Dene Care Home Address Holywell Dene Holywell Whitley Bay Tyne & Wear NE25 0LB 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 Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Holywell Dene Care Home is a purpose built facility, built in 1993, 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 with tables, chairs and benches, pots of flowers and a water feature. Some people choose to sit here during better weather. 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 two double rooms, 35 of which have en-suite facilities. There are six bathrooms providing assisted bathing and an additional shower room. There are a further thirteen W.C. facilities provided at Holywell Dene. Fees range from £378-£420 per week. Information is available for new and prospective service users, which outlines services provided in the home. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report of an unannounced key inspection, which took place over two days on Wednesday 30 August 2006 and Wednesday 6 September 2006. The inspection visit took seven hours and the Registered Manager Heather Laidler was on duty on both days. There were 42 service users at the time of the visits. Staffing levels were checked and time was spent on a tour of the building to check maintenance, cleanliness and decoration. A medication round was observed. Four care plans were examined during the inspection and an additional care plan checked as part of a complaint investigation. During site visits I spoke with eight service users, two visitors, five staff on duty and the manager. What the service does well: What has improved since the last inspection? Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 6 The home is now fully staffed. The manager continues to encourage staff to take part in training and shows a commitment to NVQ training. Access to the NVQ programme has improved and four staff are working toward NVQ level 2. A further three staff are due to begin in September. 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. Holywell Dene Care Home DS0000000609.V295981.R01.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 Holywell Dene Care Home DS0000000609.V295981.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 & 5 Service users have their needs assessed and are given assurances that these will be met. Service users know that the home will meet their needs. Prospective service users are encouraged to visit before making a decision to move in, so that they can make a decision about whether the home will suit them. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service EVIDENCE: Holywell Dene Care Home works to an admissions policy and assessment documentation is of a good standard. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 9 Four case files were examined during the inspection and show that care managers carry out the assessment of service users needs in most cases. The manager or deputy also carries out an assessment to decide whether the home can meet the needs of each individual. In private admissions the Manager carries out an individual assessment with each person. 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. In addition to case tracking, records were examined as part of a complaint investigation. In this case the admissions policy was adhered to and on the basis of the service user’s abilities and the care manager’s assessment of needs the home gave assurances that needs could be met. It became apparent that the needs of the service user were masked by medication and as her behaviour and needs changed an alternative placement was sought. The home manager and the care manager acknowledge that the needs of the individual were more complex than initially assessed. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Service users needs are set out in a plan of care so that staff may meet identified needs. Health care needs are met. Holywell Dene has a satisfactory policy for dealing with medication. On the whole residents are treated with respect and privacy is safeguarded. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service EVIDENCE: Four 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. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 11 Files contain risk assessments and action plans to deal with identified risks. Assessments are in place for pressure area management, nutrition, falls, moving and handling and continence. The changing needs of individuals are monitored and care plans are reviewed in line with this and support given Sensitive information is dealt with confidentially and daily records reflect an awareness of service users needs. Service users have access to a range of health professionals including GP’s, district nurses, dentist, chiropodist and optician. Appointments are recorded and families informed or transport arranged. In addition a further case file was examined as part of a complaint investigation and on the whole daily records were well maintained, observations and doctors visits noted. Staff had however failed to record when the care manager and the community psychiatric nurse made visits to the service user. Discussion with the manager and records indicate that in the case of the complaint made on the 22/8/06, the service user and her family were not always responded to with respect. Tension and anxiety regarding the behaviour and needs of the service user is apparent from the records. Requirements have been made relating to the supervision and training of staff with regard to these matters. Observation of staff during inspection visits confirms that people are treated with respect and that staff members show awareness of the needs of each person. Staff were observed to address people as they wished and to knock on doors before entering. There is a medication policy at Holywell Dene and seven staff members are trained and take responsibility for giving medication. An observation was made of the medication round and this confirms that the policy is being followed at Holywell Dene. Staff demonstrated awareness of the policy and procedures during inspection. There is a policy in place to support people to administer their own medication however currently no one in Holywell Dene chooses to do so. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Some activities are provided for service users to enable people to benefit from stimulation and enjoyment. 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. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Activities are organised by an activities organiser at Holywell Dene and include chair exercises, quizzes, bingo, films, a shopping trolley, games, nail care and the hairdresser visits weekly. Posters are displayed on the notice boards. There was no evidence of activities during inspection visits. The activities Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 13 organiser was elsewhere and people I spoke with said there were few activities available that they liked. One person said “There is not much going on during the day that I like, I’m not that keen on joining though” Another person said that they enjoyed time spent in their room and liked reading the newspaper. People who live in Holywell Dene are encouraged to go out within the local community to the local shop. 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 activities organiser can organise activities on one to one basis with individuals. Lunch on the first day of inspection was baked ham or sausages with mashed potatoes and vegetables. People had been given a verbal choice as to which meal to have however menus displayed were in small type and difficult to see and bore no relation to the food available. This issue was discussed with the manager and she agreed that menus should be available in different formats and should reflect what is on offer. The kitchen caters for special dietary requirements and currently provides suitable food for a number of people with diabetes in the home. Drinks and fresh fruit are available on request in the dining rooms and information was displayed on what to do in the heat wave of early summer. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 to enable people to complain. Service users are protected from abuse. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service EVIDENCE: There is a complaints procedure at Holywell Dene. 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. A complaint made to CSCI on 22 August 2006 had not been recorded in the home’s complaint file, as the manager had not received a formal complaint from the family. Where complaints have been recorded, action has been taken which complies with the policy in the home. There is a whistle blowing policy at Holywell Dene and the manager has included further POVA training for staff in her training plans. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected 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, which is suitable for their needs. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service EVIDENCE: There is a good standard of décor and furnishing in Holywell Dene and sitting rooms and dining rooms are well appointed throughout the building. Decorators were in the building during inspection visits working on communal lounges, dining rooms and the foyer. New curtains have been purchased and service users have been encouraged to have some say in the choice of décor and soft furnishings. The handy man takes responsibility for maintenance tasks and domestic and laundry staff ensure that the home is clean and hygienic. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service 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 27 care staff working within Holywell Dene, ten staff are qualified to NVQ level 2 and there are a further four staff members for whom NVQ training is underway. Three new staff are due to begin NVQ studies in September. The manager has begun her Registered Managers Award and hopes to complete this by Spring 2007. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 17 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. Training records confirm that induction training is undertaken with new staff and that mandatory training covers aspects of health and safety including food hygiene, moving and handling, and fire training. One record for a staff member appointed in April 2006 showed that her induction was not complete and that food hygiene and POVA issues had not yet been covered. All other elements of the induction programme had been covered. Induction training was discussed with the manager and she gave assurances that she would address gaps in the induction training process with this staff member. Southern Cross is in the process of introducing a new induction system for new staff, which covers all policies and procedures in the company and issues of good practice. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, 37 & 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. Service users best interests are safeguarded by policies and procedures however record keeping requires improvements to meet this standard. The health, safety and welfare of service users and staff is promoted and protected. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 19 EVIDENCE: The manager has worked within the care sector for some considerable time and has experience in day care, domiciliary care and 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 assessment process with CSCI to be judged a fit person to manage the home and demonstrates insight and skills in line with her duties as manager. The manager has begun the Registered Managers Award and hopes to complete by Spring 2007. 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. Work has begun on staff supervision however records are brief and the purpose of supervision is unclear. Supervision aims and objectives were discussed during the inspection and the manager intends to develop meaningful supervision with all staff on a regular basis, which will be recorded. Supervision records will form the basis of training needs planning for staff and will identify issues where support is required.. 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. Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 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 3 X 2 3 3 2 2 3 Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 21 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 OP12 Regulation 16 (2) (m) (n) Requirement The routines of daily living and activities made available should be flexible and varied to suit service users’ expectations, preferences and capacities. Service users should be enabled to make decisions in all aspects of their daily lives. Menus should be provided in easy to read formats. All complaints should be recorded and investigated as indicated in the complaints policy All staff should be instructed during induction on how to treat service users with respect at all times. New members of staff should receive comprehensive induction training Quality Assurance systems should be in place to assess the views of service users The manager must ensure that formal supervision is provided to staff and that written records are kept. Outstanding Requirement 10/1/06 DS0000000609.V295981.R01.S.doc Timescale for action 01/12/06 2. OP14 12 (2) (3) 01/12/06 3. 4. OP16 OP10 22 (8) 18 (c )(i) 01/11/06 OP30 01/11/06 31/01/07 01/12/06 5. 6. OP33 OP36 24 (1) (a) (3) 18 (2) Holywell Dene Care Home Version 5.2 Page 22 7. OP37 17 (3) (a) Records required by regulation for the protection of service users should be maintained, up to date & accurate. 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 23 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 © 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 Holywell Dene Care Home DS0000000609.V295981.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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