Inspection on 23/11/05 for Holcroft House

This inspection was carried out on 23rd November 2005.

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

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

Other inspections for this house

Holcroft House 01/10/08

Holcroft House 04/10/06

Holcroft House 30/09/04

Holcroft House 06/07/04

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

CARE HOMES FOR OLDER PEOPLE Holcroft House Holcroft Road Thornhill Southampton Hampshire SO19 6GH Lead Inspector Jan Everitt Unannounced Inspection 23rd November 2005 10:00 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 Holcroft House DS0000039239.V254735.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. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holcroft House Address Holcroft Road Thornhill Southampton Hampshire SO19 6GH 023 80 402689 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) Southampton City Council Mrs Ann Jewell Care Home 36 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (36) of places Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2005 Brief Description of the Service: Holcroft House is a residential home that accommodates up to 36 persons 65 years and over in need of assistance with personal care. The home is also registered to accommodate up to 6 people in the dementia care category. The home also offers a respite care service for appropriate admissions when accommodation is available Holcroft House is managed by Southampton City Council. The home is located in a residential suburb on the east of Southampton city, which is approximately three miles from the home. Accommodation for service users is in individual rooms in a single storey building. The home has three lounges and one room designated as a smoking lounge. A large dining room overlooks a courtyard area garden that service users enjoy the use of during the finer weather. At the time of this inspection the local authority was in discussion with the CSCI about the changes proposed in the home in the coming year. The first phase of the project is to redecorate and refurbish eight bedrooms and refurbish bathrooms in that area of the home to accommodate eight elderly people with mental frailty. A further two projects are planned during the next phase to be completed by April 2006 and this will include the other two areas of the home to be refurbished with the creation of more communal space in each area and an upgrade in the general accommodation. All this accommodation will gradually accommodate elderly people with mental frailty. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 23 November 2005 over a oneday period. This was the second inspection for this inspection year 2005/6. The registered manager, Mrs. Ann Jewell, assisted the inspector throughout the process. The inspector toured the building and spoke to a number of service users and staff on duty at the time. The inspection focused on the requirements made from the last inspection in April 2005 and looked at the remaining core standards to be assessed during this inspection year. Nineteen standards were assessed on this occasion, two of which were found to have minor shortfalls. The service users spoken with reported to be happy living in the home. A number of the service users, because of mental frailty, were unable to verbalise their opinions and expectations of the service. The staff reported feeling supported in their role although apprehensive about the changes being made to the service in the coming months. The atmosphere in the home was happy and that of a team that works well together. The ethos and overall care and services delivered in the home were good and staff displayed a caring attitude to the service users. The inspector viewed a sample of records and documentation. What the service does well: Holcroft House provides a safe, homely home for elderly people who can no longer live independently in their own homes and are in need of assistance with the activities of daily living. The home offers a respite care facility when rooms are available and this service is used fully. The service users looked well presented and clean and reported feeling cared for by ‘wonderful staff’. The service users, relatives and staff are being widely consulted about the forthcoming changes both environmentally and the type of service Holcroft House will be offering in the future. The alterations and refurbishment of the building commenced within the previous week and notices were seen around the home to inform people that this was taking place. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 6 The staff team work well as a team and the registered manager considers she has a loyal team that supports her and the coordinators in their roles. The housekeepers maintain a high standard of cleanliness around the home. The activities programme for the Christmas period has been planned well in advance and is very busy. Service users were talking about the raffle prizes on display in the reception area, which had all been contributed and were very impressive. The manager reports that staff are very motivated to ensure the service users have a good Christmas. What has improved since the last inspection? 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. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 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 Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 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): The standards in this section were not assessed on this occasion. EVIDENCE: Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 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 the following standard(s): 7, 9 & 11 Service user’s health, personal and social care needs are set out in individual care plans. Service users are protected by the home’s policies and procedures for the management of medicines. Service users and their families are assured that at the time of the service user’s death that staff will treat them with dignity and their privacy upheld. EVIDENCE: The home has a key worker system allocates staff to a number of service users to oversee their care and document and evaluate the care plans. The inspector viewed a sample of care plans, which were well documented with a good social history. The daily records record what care the service users have received throughout the day. Daily living plans are in each bedroom and these document how the service users prefer to undertake the activities of daily living. The inspector viewed generic risk assessments included in the care plans and noted that this included moving and handling risk assessments and care plans on how the service user mobilises or needs to be moved with assistance. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 10 Policies and procedures are in place for the ordering, receipt and management of medication. The senior care coordinators are responsible for the administration of the medication, all of who have received appropriate training. The inspector viewed the MAR sheets, which were recorded appropriately and indicated reasons for medicines not being administered. The inspector discussed with the manager that the policy did not include covert administration of medicines. She reported that this does not take place at the moment, but that this will be added to the new policy in future. Discussion took place as to the reasons and the policies that should underpin this practise, should this be necessary. The manager reported that the home prefers to maintain a service user in the home should they be at the end of their lives. This is possible with the support of the community nurse team and the GP and also the palliative care community team. Service users wishes with reference to their care through the terminal stages of their life and following death are recorded, if possible, on initial assessment, and relatives are welcomed to the home and supported to be with the person who is dying. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 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 the following standard(s): 12 & 14 The life style of the service users in the home matches their preferences and expectations and meets their social, recreational, cultural and religious needs. Service users are able to exercise choice and control over the decisions about their daily lives. EVIDENCE: Service users interests and social history is recorded at the initial assessment on admission to the home. The activities programme covers a broad spectrum of interests to attempt to accommodate service user’s preferences. The inspector observed a busy programme of activities up until Christmas that was displayed on the notice board in the reception area. The Christmas programme and menus were also displayed in the dining room. The manager reported that the home has an activities programme, which usually takes place during the afternoons and is organised by the afternoon staff. The inspector spoke to the service users and some reported that they enjoyed the musical events and another saying she enjoyed the games of skittles. At the time of the inspection a number of service users were sat in the lounge watching the television and some had gone to sleep. Those service users spoken with on the tour of the building told the inspector that they preferred their own company and liked to stay in their own rooms to read or watch television. The home has daily newspapers delivered to the home and some service users Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 12 were observed to be reading them. Another service user was observed to be going out to the local newsagents to buy his own paper, which the manager reported was an important part of his daily routine. The clergy visit the home monthly to give communion and at other times should a service user request this. The manager reported that a number of staff are to be trained in the use of sensory therapies to enable them to plan alternative programmes for those service users suffering from mental frailty. Service users are able to manage their own finances should they wish to do so. The inspector observed that a number of the service users has personalised their rooms with their own belongings, which they are able to bring to the home at the time of admission, which is stated in the service users guide. Service users spoken to by the inspector confirmed that they are able to undertaken their activities of daily living as and when they choose to do so. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 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 the following standard(s): 16 & 18 Service users and their relatives can be confident that any complaints they may wish to make are listened to and acted upon. The service users are protected from abuse. EVIDENCE: The home has a complaints policy in place. The complaints policy flow chart was observed on the office wall. It detailed the trail of how to make a complaint and if not satisfied to whom you direct it at the next level. It appears a complex trail and does not mention the CSCI as an integral part of the process. The service user information booklet that is available readily in the home and is on display around the home, directs service users/relatives how to make a complaint. It does not include the name, address and contact number of the CSCI as being part of this procedure. The Commissions address and contact number is listed in this booklet as a ’ useful contact number’. The home has the Hampshire Adult Protection procedure in place. Training on the procedure should abuse be suspected or reported, forms part of the induction-training programme. The manager reported that most of the staff have, or are in the process of undertaking the training about abuse that is delivered by Southampton City Council. The home has a policy in place on dealing with aggression/violence. The officer in charge reported that no form of restraint was being used in the home at the time of inspection. Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 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 the following standard(s): 19, 25 & 26 Service users live in a safe, comfortable environment. The home is clean, pleasant and hygienic; however, there was an area in the home identified as in need of cleaning. EVIDENCE: The home is undergoing environmental changes and refurbishment. The first stage of the project is underway and eight bedrooms have been taken out of service to enable them to be redecorated and refurbished. This project is ongoing until April 2006 and as one area of the home is completed, another section will be taken out of service. The inspector viewed minutes of meetings with the service users and relatives explaining the changes and reasons as to why some service users may well need to change rooms temporarily whilst work is undertaken. The manager considers that the service users and their significant others have been well informed and consulted on the changes. The inspector observed notices around the home informing of where the work is taking place. The inspector spoke with a number of service users who were not Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 15 disturbed by the changes and some of whom said that they were looking forward to having the large trees outside their windows lopped and therefore enabling more light into the rooms on that side of the building. Full discussion and consultation with the CSCI have taken place about the alterations. Discussion is also taking place with architects about the area of the home that is only accessible by two steps and renders it inaccessible to those who are not fully mobile. The covering of these steps has been discussed previously and the surveyor is drawing up alternative plans to ramp this area and therefore provide access for all service users. The inspector observed that the existing bathrooms, although large, only contained a bath with a chair hoist and a floor level sink. This was discussed with the manager and subsequently the surveyor and this will be addressed during the refurbishment, when the sinks will be removed and hand washing and toilet facilities will be installed into these bathrooms. The exterior paintwork is in need of redecoration and this was discussed in the last report and will be complied with during the refurbishment of the building and will therefore, not be required again. The inspector viewed the laundry room. The machines are industrial and fit for purpose. The room is in need of cleaning and redecoration. The paint is flaking on areas of the ceiling and walls. The floor and stainless steel shelving was in need of a good clean and the floor behind the machines was dirty. Taking into consideration the building works in progress, the remainder of the home was very clean and free from offensive odours. All areas of the home are fitted with thermostatically controlled radiators. The manager reported that when the covers were fitted the thermostats were encased in the covers and therefore, the radiators could not be adjusted as required. At the time of the inspection thermostats were being replaced on those radiators in an exposed position. The outside temperature on the day of the inspection was cold but the home was warm and service users reported they were comfortable. All taps emitting hot water have thermostat controls fitted and the inspector evidenced that the water temperatures are recorded every week. Holcroft House DS0000039239.V254735.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 28 & 29 Service users’ needs are met by the numbers and skill mix of the staff and are in safe hands at all times. Service users’ are supported and protected by the local authority’s recruitment policy and practices. EVIDENCE: At the time of the inspection eight beds were not in service but staffing levels were being maintained. The rota demonstrated that sufficient staff were on duty at the time of the inspection. The home employs a separate staff group for the kitchen and housekeeping. Agency staff do attend the home periodically to maintain staffing levels. The manager reported that 10 carers have achieved the NVQ level 2 award and 2 are undertaking at the present time, and the 4 care coordinators are in the process of working towards their NVA level 3 award. Historically all recruitment files and records are maintained at the human resource department in the local authority office and have been unavailable for inspection. Copies of the documentation held in the HR department of the local authority are maintained in the home and can be made available for inspection. The manager reported that she is involved with the recruitment process and undertakes all of the interviews, for which notes are maintained. Holcroft House DS0000039239.V254735.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, 32, 33, 35, 36 & 38 Service users live in a home that is managed by a person who it fit to be in charge, of good character and able to discharge her responsibilities fully and therefore, service users benefit from the ethos and management approach of the home. The home is run in the best interests of the service users. Service users financial interested are protected. Staff are regularly supervised. The health, safety and welfare of service users and staff are promoted. EVIDENCE: The registered manager has been in post for a number of years and has a great deal of experience in working with elderly people. She has achieved her Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 18 NVQ level 4 award in management and care. She reports that she attends most of the training that the staff attend and updates her skills appropriately. An experienced staff group and 4 care coordinators support the manager in her role. The manager is line managed by the responsible individual who is the manager of the older persons services for the local authority. The manager is available to her staff most days of the week and staff meetings are held every 8 weeks at which minutes are kept. Suggestions and issues are discussed at these meetings and recently staff have been given information about the forthcoming changes to the home. Resident meetings are also held monthly and the inspector viewed a record of the last meeting, which introduced a new member of staff, discussed the coming festive season and the anticipated changes to the service. The inspector observed that there appeared good communication between staff and the management and a friendly teamwork approach. An appointed person visits the home monthly to undertake a tour of the building and to examine a sample of records and audit various aspects of the home and at which time service users are also spoken with. A copy of the report is then written and forwarded to the CSCI. The manager is involved with several internal audits around the home and reports that questionnaires are distributed to service users and relatives. The home has corporate policies and procedures in place provided by the local authority. The home does not manage any of the service users’ monies. The local authority manages these in individual accounts and the manager receives a statement every month for all service users as to the balance they have in the account. The manager maintains a float in the home for sundries that service users may request or need. An invoice and a receipt are then forwarded to finance department for reimbursement. Staff supervision does take place at least 6 times a year. The manager and the care coordinators, who supervise care staff, manage the appraisal and supervision. The home has a risk assessment of the environment. All mandatory health and safety training records were evidenced on a training matrix. The inspector observed that all substances hazardous to health were stored in a locked cupboard. A sample of servicing certificates was viewed by the inspector and was seen to be in order and current. The kitchen was visited and was clean and well organised with appropriate cleaning schedules in place. The fire logbook was viewed and appropriate training and testing of fire systems at the recommended intervals, were recorded. Accidents are recorded and appropriate Regulation 37 notices of incidents are returned to the CSCI. Holcroft House DS0000039239.V254735.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 20 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 Standard OP16 Regulation 22(7)(a) Requirement The complaints policy must contain the address and contact number of the Commission for Social Care Inspection. Whilst the Commission have been made aware that the local authority is working to comply with this requirement, at the time of the inspection, this remained outstanding. The flaking painted walls in the laundry room must be repaired and floors and shelving in this room must be cleaned to an acceptable standard. Timescale for action 31/01/06 2 OP26 23(1)(d) 31/01/06 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 Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Holcroft House DS0000039239.V254735.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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