Inspection on 01/05/07 for The Hollands Nursing Home

This inspection was carried out on 1st May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Hollands Nursing Home 2 Church Road Farnworth Bolton Lancashire BL4 8HQ Lead Inspector Mike Murphy Unannounced Inspection 1st May 2007 09:03 X10029.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 The Hollands Nursing Home DS0000069177.V337168.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 and Care Homes for Adults 18 – 65*. 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. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollands Nursing Home Address 2 Church Road Farnworth Bolton Lancashire BL4 8HQ 01204 574386 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) The Hollands Care Homes Ltd Mr Sajjad Ahmed Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (16) of places The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, (maximum number of places: 24). Physical disability - Code PD, (maximum no of places: 16). The maximum number of service users who can be accommodated is: 40 Date of last inspection New Service Brief Description of the Service: At The Hollands care home care services are provided in a large adapted property built on two levels with a passenger lift to the first floor.The Hollands Care Home provides a total of 24 places for both nursing and residential care for elderly people and 16 places for the care of young physically disabled Service Users. 32 bedrooms are of single occupancy and four are shared. The home which has an adjacent garden area, is situated off the main street in Farnworth about three miles from Bolton town centre, is close to main bus routes and there are shops within walking distance. Information provided by the home states the current fees for older persons are from £355.39 and from £599.36 for younger adults. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit took place over seven hours. The inspector spoke to 7 of the 24 residents, 3 relatives and 4 members of staff, toured the premises, and inspected care and other records maintained at the home. The standards inspected included those concerned with how residents are assessed and their health and personal care, activities provided, the environment, meals provided by the home, how complaints are dealt with, staffing levels, and how resident’s safety is protected. Residents throughout the home appeared to be well cared for and content within their environment. However a number of issues were raised and are identified below and in the body of this report. What the service does well: What has improved since the last inspection? What they could do better: There is a need to review the overall provision of leisure and social activities provided for residents with a view to arranging more organised outings. The home also need to obtain an up to date gas safety certificate and plan a decoration/refurbishment programme for the communal areas on the first floor of the home and the bedrooms generally. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 OP and standard 2 YA. Standard 6 OP does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All Prospective residents are suitably assessed and are encouraged to make trial visits to the home prior to admission. This is important to enable prospective residents to make informed choices about the suitability of the home for them and to ensure that the home is able to meet the needs of such prospective residents. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 9 EVIDENCE: Inspection of four residents care records revealed that each had undergone a pre admission assessment by the home manager or his deputy – both are qualified nurses. These assessments included consideration of prospective residents physical, psychological and social needs. And were supported by others conducted by a variety of health and social care professionals such as doctors, nurses and social workers. The inspector spoke to 4 individual residents – 2 older persons and 2 younger persons and 2 relatives about their admission experiences – all were of the view that the home was meeting the needs of residents. An example of comments made to the inspector included ‘ I came to the home a couple of times before I made my final decision and was able to talk to the residents and staff about the home as well as see what it was like for myself. The manager and staff were very helpful with this’. ‘I was able to be present when the home came out to assess my mum and felt we were both consulted throughout and although it was not appropriate for mum we were offered a trial visit – however I had visited the home without telling them I was coming before’. All placements of residents are formally reviewed shortly after admission and periodically thereafter. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 OP. 6,9,16,18,19 and 20 YA. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents were being met so as to maximise each persons quality of life. EVIDENCE: The health care records of 4 residents were inspected – 2 older people and 2 younger adults) out of a total of 24. living at the home at the time of The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 11 inspection. All contained care plans based initially on the pre-admission assessment referred to in the last section of this report. Care plans identified issues and detailed how staff were to care for residents who had a variety of health and social care needs. Care plans had been evaluated at least monthly. Risk assessments that aim to minimise risk to the health and safety of residents were recorded for skin integrity, mobility, and nutrition (including weight monitoring) and other areas of potential risk and were evaluated at least monthly. The arrangements for resident’s medicines were secure and properly documented and have significantly improved since the random inspection by a CSCI pharmacist inspector on the 21st of March 2007 that was conducted after some concerns were raised regarding the management of medicines at the home. The manager has reviewed all aspects of medication management and implemented a process of monitoring where any problems in this area can be detected early and acted upon. Both requirements made by the pharmacist inspector had been complied with. Residents confirmed that staff treat them respectfully and seek to ensure their right to privacy and dignity are maintained. Comments made by residents included ‘the staff are friendly and treat me well’, ‘I don’t feel embarrassed when the staff are looking after me as they make me feel ok about the situation,’ my mum says the staff treat her well and I am sure she would tell me if that was not the case’. It was clear following talking to residents, relatives, staff and inspection of care records that residents are able to receive health care services appropriately, this included access to dieticians, opticians, dentists, and chiropodists. All residents were registered with a local GP. Relatives felt that they were kept informed of all-important changes in their relation’s health. The type of care and support required by older people and younger adults is clearly very different. These differences were clearly reflected in the care records of each group of resident’s within the home. Care planning was based on the care and support individual resident’s required. The care of all resident’s is supervised by qualified nurses who cover the home 24 hours per day. All residents appeared to be being cared for appropriately on the day of this unannounced inspection. This included the provision of appropriate aids and adaptations such as appropriate beds, chairs and other equipment required to meet the needs of residents. However it was noted the personal sitting chairs of 2 residents on the younger persons unit were considerably worn/ damaged in places. The inspector was informed by the deputy manager that arrangements had been begun to rectify these issues. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 OP. 12,13,15 and 17 YA Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to have some choice and control over their lives. However more opportunity for activities outside the home need to be developed to improve the social and leisure time of residents. EVIDENCE: A range of leisure activities was available to residents and it was evident that residents had been consulted about the programme of activities at resident meetings held at the home. However the view was expressed to the inspector, The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 13 particularly by some of the younger residents that some of these were not appropriate for their age group and that there should be the opportunity to go on organised trips out. The inspector is of the view that the range of social and leisure activities should be extensively reviewed – in consultation with all groups of residents (and relatives). It is noted that periodically entertainers come to the home. A computer for the use of residents has been purchased. The inspector was informed that the home was in the process of arranging internet access at the time of this inspection. Residents said that the daily routine at the home were as flexible as possible in a communal living setting – on the day of inspection residents were getting up at various times of the morning and were provided with a breakfast of their choice. A number of residents had brought in some items of furniture for example a favourite chair and other personal mementos. The ability to do this is important to enable residents to retain as much personal choice in their lives as possible. Residents and their relatives say there were no unreasonable restrictions to visiting at the home – which can be conducted in communal lounge areas or residents own bedrooms. Menus were balanced, varied and provided reasonable choices. Meals for elderly residents are currently served in a pleasant and appropriate dining area on the ground floor. This area has been recently redecorated and refurnished. Currently the younger residents take their meals on the first floor of the home on the designated younger persons unit. The lounges/dining area on this unit are in need of improvement to bring them up to the same standard as the ground floor. Meal times are reasonable and as flexible as they can be in a group living environment. Breakfast and lunch were observed on the day of inspection. These meals were suitable and staff assisted and served residents their meals appropriately. Residents indicated that they were happy with the quality and quantity of food provision and said that if they did not like what was on the menu a reasonable alternative was provided – and they felt comfortable enough to ask for this. The inspector was informed that there had been recent issues around the quality and presentation of meals provided for residents who needed a pureed (‘soft’) diet. The manager in discussion with residents/relatives had resolved these issues with the catering and care staff – this issue is subject to review by the manager. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 OP. 22 and 23 YA. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are enabled and feel able to make a complaint if it was felt necessary. Policies and procedures of the home seek to protect residents from potential abuse. EVIDENCE: The complaints procedure was prominently displayed and accessible. Residents spoken to said any issues they raised were taken care of quickly by the manager. A complaints record is maintained. Issues appear to be addressed appropriately, in a reasonable time and the outcome is recorded. The Hollands Nursing home operates ‘abuse and whistle blowing’ policies that seek to protect elderly persons – the inspector was informed that these (along with the other policies being operated by the home) were currently being reviewed. A copy of Bolton’s Inter agency protection procedure is held on site – that informs home managers how to report and manage any instances of suspeted abuse of residents at the home to enable the matter to be investigated quickly and transparently. Staff spoken to confirmed that they had received protection of vulnerable adults training and this was confirmed The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 15 following the inspection of training records maintained by the home. They were also aware of the whistle-blowing policy. Whilst it is evident that this training is provided at the home it is reccommended that staff should also be periodically enabled to access protection training provided by the local authority in relation to protection of vulnerable adults. This will ensure staff keep up to date with local developments and practice in this very important area. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24 and 26 OP. 24,26,28,29 and 30 YA. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home provides a suitable environment for residents there are some decorating/refurbishment issues that need to be addressed to improve the quality of the home environment for all residents. EVIDENCE: The Hollands was clean and free of malodour throughout on the day of this unannounced inspection. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 17 The ground floor currently provides accommodation for the elderly residents at the home. 10 elderly residents were being accommodated at the time of this inspection. 4 resident’s bedrooms were inspected on this occasion. These were clean, warm, appropriately furnished (although some bedside cabinets and wardrobes are beginning to look worn and marked) and decorated. One bedroom (18) – not currently in use had sustained a damaged ceiling (as the result of a now fixed leaking roof). The main lounge area on the ground floor is pleasantly and appropriately decorated, furnished and carpeted. New lounge chairs have now been provided. The dining room is appropriately decorated and furnished. Residents on this unit felt that their own rooms and lounges were kept clean, warm and were comfortable. They also said their beds were changed regularly (this is also recorded in the care records of residents). The 1st floor currently provides accommodation for the younger resident’s at the home. 15 younger residents were being accommodated at the time of this inspection. 5 resident’s bedrooms were inspected on this occasion. These were clean, warm, appropriately furnished (although again some bedside cabinets and wardrobes are beginning to look worn and marked) and adapted. The communal areas on this unit were clean but the décor is quite marked in places and some of the furniture is quite worn and marked – these areas are quite a contrast to the environment on the ground floor and need to be refurbished. Such a refurbishment should be conducted in a way that is appropriate for the particular resident group that is to live on that unit. Residents on the younger residents unit who were spoken to indicated that their bedrooms and communal areas of the home were kept clean, warm and comfortable. Aids and adaptations available at the Hollands include assisted bath and shower facilities, portable hoists, raised toilet seats, and grab rails. Accessible call alarms were available in all rooms. Individual disability equipment requirements are addressed following referral to the appropriate health care professional for assessment. A Passenger lift enables younger residents to access all areas of the home – including the separate ‘smoking’ lounge area on the ground floor of the home. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 OP. 32,34,35 and 35 YA. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing provision was adequate to meet the assessed needs of residents who were in the home at the time of this inspection. However in view of the high number of residents with apparently high dependency levels the staffing provision needs to be constantly reviewed by the home to ensure any changes in the overall numbers of residents and in resident’s dependency levels are responded to appropriately. EVIDENCE: The numbers of qualified nurses and care staff appeared to be appropriate to meet the needs of both elderly and younger resident’s. Qualified nursing staff supervises Resident’s care. Whilst the number of such staff was satisfactory at The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 19 the time of inspection – when only a total of 13 residents in the home were assessed as requiring ‘nursing care’ (the remaining 11 being assessed as requiring ‘residential/personal’ care) – the registered manager should regularly monitor this provision. In particular the possible need to have 2 qualified nursing staff on duty at all times during the day (and not just the weekday mornings as is the current practice – it is noted that 1 qualified nurse is on duty at weekends). It is not the total number of residents who require ‘nursing’ care that determine the numbers of qualified nurses on duty but the dependency levels of residents and the layout of the building – in this case care is being provided on 2 floors of the home to ‘nursing’ residents. The provision of care staff should also be constantly reviewed in respect of resident’s dependency levels. 3 staff personnel files were inspected at random. These contained an application form – including health declaration, rehabilitation of offenders declaration, 2 written references and evidence of CRB checks, POVA ‘first’ checks, record of induction training and proof of identity. The qualifications and registration status of nursing staff are regularly checked. Induction training has been provided as well as ongoing training of staff to meet the assessed needs of residents, and this training has been formally recorded. The inspector was informed in written information provided by the home manager that over 70 of the care staff employed at the home have obtained an NVQ2 qualification or above. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, and 38 OP. 37,39 and 42 YA. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is experienced and competent ensuring that the home is run in the best interests of the residents, ensuring their health, safety and well-being. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered home manager is an experienced registered nurse who has worked in senior positions in the care of older and younger people many years and is studying for the equivalent of an NVQ4 qualification in management. Resident’s and staff say that the manager and his deputy are adopt a management style that is open, fair and inclusive. A number of quality assurance systems to assess the success of the home in meeting its aims and objectives were in operation. These included the use of resident/relative questionnaires, in house quality monitoring, and resident/staff meetings. Residents care records were kept safely and the residents may have access to their records if so desired. Whilst the manager makes use of some audits in his programme of quality assurance this needs to be extended to measure the quality of all the aspects of the services provided by the home. It is recommended that an appropriate system to achieve this be implemented. Written information provided to the CSCI by the registered manager prior to this inspection indicated that maintenance/equipment servicing is up to date. However it became evident during the inspection that the annual gas safety inspection certificate had expired shortly prior to the inspection. The need to arrange a gas safety check was discussed with the deputy manager at the time of inspection. Fire safety training has been provided for all staff employed at the home. The arrangements for managing residents personal allowances were secure, appropriately documented/receipted and audited on a regular basis. The deputy manager informed the inspector that the responsible individual for the Hollands care homes Ltd visits the home regularly. However the inspector was unable to inspect the written report that is required to be completed following these visits. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 22 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 X 2 X 3 3 4 3 5 X 6 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 2 21 X 22 3 23 X 24 2 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 2 The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 23 N/A 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 Standard OP12 YA14 Regulation 16(2)(m) 16(2)(m) 13(4)(c) 13(4)(c) 26 26 Requirement You must review in consultation with residents the existing provision of social and leisure activities for residents You must provide written confirmation to the CSCI that a gas safety check has been conducted by a competent person in respect of the home You must keep the written reports made following the visits to the home by the Responsible individual (or the person nominated to conduct these visits) available for inspection by the CSCI You must ensure that staffing provision within the home is continually monitored to ensure it is adequate and appropriate to meet the needs of residents at the home. You must develop and implement a programme of redecoration/refurbishment that addresses the environmental issues detailed in this report Timescale for action 30/06/07 2 OP38 YA42 30/06/07 3 OP38 YA43 30/06/07 4 OP27 YA33 19 19 30/06/07 5 OP19 YA24 23 23 30/06/07 The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 24 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 OP33 YA39 Good Practice Recommendations Whilst the manager makes use of some audits in his programme of quality assurance this needs to be extended to measure the quality of all the aspects of the services provided by the home. It is recommended that an appropriate system to achieve this be implemented. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. The Hollands Nursing Home DS0000069177.V337168.R01.S.doc Version 5.2 Page 26 - 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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