Inspection on 14/11/06 for Hollies Care Home

This inspection was carried out on 14th November 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 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

Hollies Care Home 30/10/07

Hollies Care Home 27/10/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Hollies Care Home Reading Road Burghfield Common Reading Berks RG7 3BH Lead Inspector Stephen Webb Unannounced Inspection 14th November 2006 09:45 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 DS0000065501.V305723.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. DS0000065501.V305723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollies Care Home Address Reading Road Burghfield Common Reading Berks RG7 3BH 0118 983 2254 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Ms Christine Ann Deady Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places DS0000065501.V305723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: The Hollies Care Home is now operated by Southern Cross Healthcare. The home is registered for fifty-eight male or female individuals over retirement age, and provides residential and nursing care. Accommodation is provided in 56 single bedrooms and one double room, which is only used as such where two people expressly wish to share. The Home has a newer two-storey wing that has been added to the older part of the house and provides 27 en-suite bedrooms, additional assisted bathing facilities, and lounge and dining rooms to both floors. The home is situated in a quiet semi-rural area with views at the rear over farmland and has an enclosed paved central courtyard with seating provided, which provides much of the useable garden area. Fees at the time of inspection ranged from £560 to £750 per week. DS0000065501.V305723.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 9.45am until 7.15pm on 14th of November 2006. The inspection also included reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversations with service users, a relative, management and staff at the unit, also from twenty six returned service user questionnaires, some of which were completed by relatives or staff with or on behalf of service users. The questionnaires were in two separate batches returned in July 2006 and a later batch returned in September 2006. The inspector also toured the premises and had lunch with service users. The home is now operated by Southern Cross Healthcare and has had three changes of manager in the past year. What the service does well: Up to date information about the home is made available to prospective and existing residents or their representatives. A thorough pre-admission assessment is undertaken to identify the needs of a prospective resident and ensure they will be met, and this is followed by a detailed post admission assessment process from which the initial care plan is compiled. Care plans are detailed and regularly reviewed. The healthcare needs of residents are identified and addressed, and records are retained to evidence this. Each resident has an identified key worker and allocated nurse, whose names are posted in their bedroom. The home has an appropriate medication management system, and medication is only administered by trained staff. (See below). Residents are offered a good range of activities and have opportunities to go on some outings in the community. The activities coordinator works to try to find activities to meet everyone’s needs. Residents spiritual needs are also provided for, through visiting clergy. Contact with family is supported and encouraged by the home. Residents are enabled to make day-to-day choices about aspects of their daily lives and have been consulted about issues in the home. DS0000065501.V305723.R01.S.doc Version 5.2 Page 6 Residents receive a balanced diet through the recently reviewed menus, which contain meals chosen by the residents. The complaints procedure is posted in reception and also provided within the statement of purpose and service user guide. Feedback from residents / relatives indicated they had confidence in the current manager to take on any issues raised. Appropriate systems are in place to protect residents from abuse and staff receive training in the protection of vulnerable adults (POVA), from an accredited trainer. The environment is pleasantly decorated and furnished, as well as addressing health and safety issues, and appropriate adaptations are present to meet residents’ needs. Standards of hygiene are good. Staffing levels and skill mix appeared broadly appropriate to meet residents’ needs, though some residents / relatives questioned this. (See below). Staff receive a good core training and all shifts are staffed by a team of nurses and care staff. The residents are protected by an appropriately rigorous recruitment system, and systematic records are maintained to evidence this. The home has appropriate systems in place to protect the finances of residents where it manages these on their behalf. Systems are in place to protect the health and safety of residents. What has improved since the last inspection? It was reported by some residents and relatives that staff morale and the quality of care had improved since the current manager’s return. New menus have been produced based on consultation with residents and the meals they asked to be included. Good progress has been made on NVQ attainment by the care staff. Very few shifts include agency staff now, following a successful round of recruitment. An appropriately experienced and qualified manager is now in post, following a period of management changes. Feedback indicates that residents and relatives have confidence in the new manager. A number of effective tools are now in place to monitor the quality and consistency of care. DS0000065501.V305723.R01.S.doc Version 5.2 Page 7 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. DS0000065501.V305723.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000065501.V305723.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Up to date information about the home is made available to prospective and existing residents or their representatives on an individual basis. A thorough assessment is undertaken to identify the needs of a prospective resident and ensure they will be met, prior to their admission, and is followed by a detailed post admission assessment process from which the initial care plan is compiled. Standard 6 is not applicable. The home does not provide a designated intermediate care service. DS0000065501.V305723.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home’ s statement of purpose details a comprehensive assessment procedure, both pre-admission and post-admission. The home manager usually undertakes pre-admission assessments herself, usually by means of a visit to the prospective resident at home or in hospital, though a prospective resident could be assessed upon visiting the home if preferred. The prospective resident or their next of kin are encouraged to visit the home prior to making a decision to come, and all admissions are subject to a fourweek trial period on both sides. Copies of the home’s statement of purpose and service user guide are provided. Residents or their representative are also provided with a statement of terms and conditions. Discussion with the manager during the inspection confirmed that the assessment practice was as described, and examination of a sample of the resident’s files showed pre-admission assessments to be present as well as post admission assessments and care plan documents. The service user guide and statement of purpose had been updated just prior to this inspection, though the documents were not dated to indicate this, and were in the process of being distributed to each resident/their representative. A copy of the statement of purpose was also available in the entrance hall, together with details of the complaints procedure and copies of the complaints form, which is good practice. DS0000065501.V305723.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs and preferences of individual residents are recorded within detailed care plans, which are regularly reviewed by the home. The care planning and assessment systems identify healthcare needs effectively, and the home maintains good records to indicate how these are addressed. Each resident has an allocated nurse and a carer, and their names are posted in the bedroom to help residents and relatives identify them, though the addition of photographs should be considered. Feedback from residents and relatives indicated that residents were treated with respect, and that staff generally respected their privacy and dignity, though some examples were given where this had not always been the case. It was reported that the quality of care and staff morale had improved since the return of the current manager. Residents’ medication is managed on their behalf by the home, and the home has an appropriate system for this. Records were satisfactory apart from a small number of recording omissions, which need to be addressed. DS0000065501.V305723.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each resident has a care plan, which is drawn up from assessment information, including a range of risk assessments and screening tools. Residents’ care plans are reviewed regularly, in house, and, if a resident receives local authority funding, the local authority also undertakes annual reviews. In one case the local authority review had not taken place despite being pursued by the manager. Each file also contains a summary record of contact with any external healthcare professionals, which might include, district nurse, tissue viability nurse, consultant, speech and language therapist, OT, dietician etc. Detailed healthcare records are maintained in separate medical files. The manager reported that only two residents had any pressure sore areas at the time of inspection, which were reducing in response to the action plan for the care provided. This figure was down from four instances a few days previously. The advice of the GP/tissue viability nurse is sought in addressing any such issues. The home has its own specialist mattresses etc. to try to prevent the development of pressure areas, where identified as a high risk as part of assessment. Where weight loss or other indicators of health problems are noted, an action plan is devised for the individual’s care. Where cot sides are used on residents’ beds these are subject to risk assessment and family consent. Each resident has an allocated key worker and designated nurse, whose names are posted in the resident’s bedroom, however a photo of the individuals might assist with identification in a home with a large staff team. The manager is considering a staff photo-board in the entrance hall, which will help visitors to identify individuals and who is in charge. Consideration should also be given to providing photos next to the staff names in bedrooms to help residents identify their allocated carers. The home operates an appropriate medication management system, and the individual records include a photograph, medication profile and allergy information for each resident with the medication administration record (MAR), sheet. The MAR sheets include a record of the quantities of medication received and there is an appropriate record of returns. The home has an onsite disposal system for controlled drugs. DS0000065501.V305723.R01.S.doc Version 5.2 Page 13 Medication is only administered by trained staff. A small number of gaps were evident in the administration records. The manager should consider the provision of a system which would reduce the risk of medication errors or errors in their recording. Feedback from residents indicates that the staff usually support the privacy and dignity of residents, though this was not universally the case. Most felt that staff responded as quickly as they could when they were called, but some residents felt that there was too long a delay at times, and that staff did not always let them know there would be a delay, though this was usually done. One of the residents spoken to was pleased to have her own telephone to make calls when she wanted, in private. One resident was being assessed for an electric wheelchair which she felt would improve her mobility and dignity, in that she would be able to move about the home more freely, without being dependent on staff to assist her. Four other residents have already been provided with these. The home’s policy on knocking on residents’ bedroom doors before entry was seen to be followed by the staff. The call system also shows a green light on the panel outside of the bedroom, to indicate that a carer has responded and is present, which enables other staff to respect the resident’s privacy and dignity. However, one person felt that not all staff were as good at respecting residents’ dignity whilst support with personal care was being given. One relative felt that residents’ needs were generally addressed effectively, now that the previous manager had returned to the home. There was a sense from available feedback, that the quality of care and staff morale had reduced after she had left, when the home went through a period of instability with two managers in quick succession and a number of staff changes, as well as changes in ownership. This was borne out by the level of issues reported within the batch of resident/relative feedback questionnaires returned to the CSCI in July, which contained a range of issues. It is hard to judge the level of improvement directly from the later batch of feedback forms received by CSCI, however, as the majority appear to have been completed in the same hand, by a staff member on behalf of residents, whereas, most of the previous forms were completed by residents or relatives directly. DS0000065501.V305723.R01.S.doc Version 5.2 Page 14 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, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a good range of activities and have opportunities to go on some outings in the community. The activities coordinator works to try to find activities to meet everyone’s needs. Residents spiritual needs are also provided for, through visiting clergy. All of the current residents enjoy some contact with family, with some being visited most days. Residents’ family can also have a say about the home via the family liaison meetings. Residents are enabled to make day-to-day choices across a range of aspects of their daily lives and have been consulted about various issues. Residents receive a balanced diet through the recently reviewed menus, which contain meals chosen by the residents. Feedback about the food remains mixed, and it may be prudent to undertake a further survey to establish whether any concerns remain current. The dining rooms are a pleasant environment in which to eat. The group is split into two rooms for dining, which together with some residents opting to, or needing to eat in their bedroom, means that the dining rooms contain reasonable sized groups. DS0000065501.V305723.R01.S.doc Version 5.2 Page 15 EVIDENCE: There is a notice board in the entrance hall detailing the wide range of activities and outings available, and also including some photos of past events. Each resident’s file contains a record of the recreational activities in which they take part, and in addition, the activities coordinator also keeps her own detailed records of those who participate or decline the activities provided, and any conversations she has with individuals. An ex-carer has now been appointed to the activities coordinator post. She works Monday to Friday, from 9.30am-3.30pm, and also provides some evening and weekend activities. The activities coordinator spends particular individual time with any residents who do not regularly take part in activities to try to find things they would like to do, and counter isolation or depression. The mobile library service visits the home regularly. The manager indicated that more opportunities for outings were now being provided, with the next one being a shopping trip to reading to see the Christmas lights. Other recent outings have included access to the “Stroke Club” and pub lunches. One resident is supported to visit his wife in hospital. The manager also indicated that a theatre group were coming to the home soon to perform. The home can access a minibus from another home in the group, but the viability of having the home’s own vehicle is being explored. The services of Readibus and local taxis are also utilized when necessary. Some residents opt not to take part in the activities provided, preferring their own company and the quiet of their room. Others confirmed that a range of outings and activities are available. In some rooms there was an issue about the poor quality of the TV reception on some channels, which the manager reported was in hand. Contact with relatives is recorded within individual files to ensure that any relevant information is passed to staff. All of the current residents were reported to have contact with family, some of whom visit most days. The manager indicated that the current relatives meeting format would be revamped to try to improve attendance. She also planned to restart regular residents meetings with an informal coffee morning theme so residents had the opportunity to discuss any issues or concerns. A residents and relatives meeting will also be arranged to discuss how to spend the Hollies Residents’ Fund monies. DS0000065501.V305723.R01.S.doc Version 5.2 Page 16 Residents confirmed that their spiritual needs are addressed via weekly visits by the priest who also holds a monthly Holy Communion service in the home, which those who wish to can attend. The manager confirmed that support for other faiths was available if required. Residents are supported to make choices in their day-to-day lives, in terms of menu preferences, the clothes they wear and whether they wish to take part in available activities or outings, or spend time with other residents or on their own in their room. Residents are able to manage their own funds if they have the capacity and wish to do so. Only one resident does this at present. Residents have been able to choose personal items to bring in with them to personalise their bedroom, and are able to see their files if they wish. The menus have recently been improved after individual consultation with residents, and there is now a four-week rotating core menu with other options available at each meal. Additional snacks and drinks are available on request. Residents confirmed they had been consulted about the new menus, and that snacks and drinks were readily available. The chef now asks residents what they like and an information sheet has been produced detailing the options available. The manager felt that there had been improvements more recently, including the provision of a specific food budget to the chef, and a greater focus on fresh ingredients. Feedback on the food provided by the home is mixed, with some having criticisms, and others reporting that meals are very good. One criticism made more than once was about the meat sometimes being tough. Given that menus have been revised recently, it may be prudent to undertake a survey of food satisfaction to obtain an up-to-date, detailed view from residents, of any issues which remain. DS0000065501.V305723.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives were mostly aware of the complaints procedure, which is posted in reception and provided within the statement of purpose and service user guide. Feedback indicated they had confidence in the current manager to take on any issues raised. Systems are in place to protect residents from abuse and staff receive training in the protection of vulnerable adults (POVA), from an accredited trainer. EVIDENCE: The home has an appropriate complaints procedure in place, which is outlined in the statement of purpose and service user guide, as well as being posted in the entrance hall of the home. Complaints leaflets, pre-addressed to the provider organisation’s head office, are readily available in the entrance hall without recourse to staff to obtain one, which is good practice. The complaints log contained only one entry in 2006, during the tenure of the previous manager, which appeared to have been resolved satisfactorily. The manager makes a point of going around the home regularly, speaking to residents, and would therefore be accessible should they have a concern to raise. DS0000065501.V305723.R01.S.doc Version 5.2 Page 18 Feedback from residents and relatives indicated that they considered the current manager more approachable and accessible than her predecessor. It was clear that she was familiar to residents. It was said that she was certainly more in evidence about the unit than the previous manager, and listened to the comments of residents and relatives. All staff receive POVA training as part of their induction and an update by an accredited in-house trainer is in process, with around twelve staff left to attend this training, booked for the end of November. The manager is also an accredited POVA trainer and will have a role in future update training for staff. One POVA issue, which arose during the tenure of the previous manager, was dealt with appropriately by the provider organisation. The home has an appropriate system and records for the management of residents’ personal allowance, where it takes on this responsibility. DS0000065501.V305723.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a good standard of physical facilities, which are pleasantly decorated and well maintained as well as addressing health and safety and security. The home is clean and hygienic, and equipped with appropriate laundry facilities to meet residents’ needs. EVIDENCE: The home’s environment was homely and pleasantly decorated and furnished. The new purpose-built wing is very spacious with wide airy corridors and goodsized bedrooms. A variety of communal areas were provided including two dining rooms, four lounges and a therapy/activities room. DS0000065501.V305723.R01.S.doc Version 5.2 Page 20 The home is redecorated on a rolling programme and maintenance is mainly carried out in-house. The remaining corridor flooring was due to be replaced with vinyl flooring to improve hygiene and appearance. All of the internal fire doors are fitted with approved electromagnetic holdback devices to enable them to remain open during the day to facilitate resident’s free movement about the home, whilst closing automatically in the event that the fire alarm sounds. External doors are fitted with alarms to alert staff should a resident attempt to exit the home without their knowledge. The main garden area consists of an enclosed paved courtyard, which was rather lacking in character and would benefit from further development. The manager had plans to undertake this next spring. Some residents also make use of the area of garden to the front of the home, but much of the ground has been built on with a series of extensions to the home. Bedrooms were attractive and homely and personalised with residents’ own items to varying degrees. A number of residents commented that they liked their bedroom and some also enjoyed the view from their window over the fields. Several preferred to spend the majority of their day in their room, reading or watching TV, perhaps coming out for meals with the group. Only one double bedroom remains, which is only used where two people express a wish to share. Appropriate curtaining is provided to offer some privacy therein. In response to a previous concern about the lack of space available for hoist use in some bedrooms, the manager had discussed some rearrangement of furniture and in some cases removal of some superfluous items, in consultation with the resident or their next of kin. As a qualified health and safety officer, the current manager is well placed to make judgements where there may be such a health and safety issue. Whenever there is an identified need, the home has a selection of hospital-type adjustable beds available and other specialist equipment, such as hoists and standing aids. The bathing facilities provide a range of adaptations and options to meet various preferences, including baths with integral hoists, parker baths and wheel-in showers. The bathrooms had been decorated in an attractive style, with decorative border tiles to add a touch of colour and reduce their tendency to appear clinical, and some also had pictures on the walls. The home also has plenty of toilets throughout. The laundry facilities were appropriate and hygiene standards appeared to be good, with no evidence of unpleasant odour. DS0000065501.V305723.R01.S.doc Version 5.2 Page 21 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents appear to be met by the numbers of staff available, though some feedback from residents/relatives did question this, and a further round of feedback from residents and relatives would clarify whether these concerns remained current or related to the period before the current manager returned. (Recommendation made under Standard 33). The residents are looked after by a well-trained staff group. All shifts are staffed by a team of nurses and care staff. Good progress has been made on NVQ attainment by the care staff. Very few shifts include agency staff now, following a successful round of recruitment. Residents are protected by an appropriately rigorous recruitment system, and systematic records are maintained to evidence this. EVIDENCE: The regular staff complement is three nurses and seven care staff on the early shift, two nurses and five care staff on the late shift and two nurses and three care staff on waking night duty. In addition the activities coordinator works Monday to Friday from 9.30am-3.30pm, and also provides 4-6 hours of activities during evenings and weekends. The care manager also works on the rota and the home manager’s hours are variable, but include some shifts. DS0000065501.V305723.R01.S.doc Version 5.2 Page 22 The majority of resident/relative feedback about their experience of the staff was positive, though some negative concerns were noted about delays in response to call bells, toileting practice and other matters. It was not easy to establish whether some of these issues were current, or related to the period before the return of the current manager, as some questionnaires dated from before her recent return. Some residents and a relative did comment that the morale of staff and the quality of care had improved since the return of the current manager, so it may be that some or all of the previous issues are no longer of concern. Certainly the care observed during the inspection was respectful and attentive, and staff demonstrated knowledge of the likes and dislikes of individual residents. Observed interactions were warm and with an appropriate degree of humour at times. No undue delays in responding to the call system were noted during the inspection. In order to clarify whether any concerns remain, a further focused quality assurance feedback questionnaire to residents on the specifics of their experience of the care provided, might be beneficial. (Recommendation made under Standard 33). All new staff now undertake a thorough organisational induction, which is recorded, signed off and dated as it is completed, which is good practice. The second part of the induction record records the signing-off of observed aspects of appropriate care practice. Good progress is now being made with NVQ with ten of the twenty-six care staff having attained NVQ level 2, and one with level 3. Two staff have completed and are awaiting certificates, one at level 2, and one level 3, and a further four staff are registered to start level 2. The manager is an NVQ assessor up to RMA level. The home also employs twelve nurses. Due to recent recruitment success, a number of staff are also still undertaking their induction, but the expectation will be that they will go on to undertake NVQ afterwards. Very few shifts now include agency staff. Examination of a sample of recent recruitment records indicated a thorough process with the required evidence being available for inspection. At the time of inspection the staff training records were on individual files, but the manager planned to compile a training matrix to enable her to maintain an overview more readily. Examination of recent training indicated input for all staff on moving and handling, fire safety, food hygiene and health and safety; and POVA training was booked for the end of November for the remaining staff without a recent update in this area. DS0000065501.V305723.R01.S.doc Version 5.2 Page 23 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is now well managed, after having been through an unsettled period of change. The current manager is well qualified, trained and experienced to manage the home. There is evidence that the home is run with the interests of the residents in mind, and a range of quality assurance and monitoring tools are in place to oversee the quality of the care provided. Given the previous period of uncertainty, and the questions raised about aspects of the care provided, it may be beneficial to undertake a focused survey of the views of residents and relatives on the care provided since the current manager’s return, to obtain an up-to-date picture. The finances of residents are safeguarded where the home undertakes responsibility for managing their personal allowance. The health and safety of residents is promoted by the home and its current systems. DS0000065501.V305723.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home has been through an unsettled period with changes of provider organisation and home management. The current manager recently returned to manage the home in August 2006, having previously been manager from 1999 to 2004, and having worked in the unit for fifteen years in total. She is well qualified to undertake the role, being an RGN and NVQ assessor up to RMA level, as well as an accredited trainer in several disciplines. The manager demonstrated a thorough understanding of the priority issues, and had already instigated a number of changes to improve practice and consistency. She is also developing evidence files to centralise paperwork and information necessary for future inspections. Feedback from residents and relatives indicates a positive impression of the manager. Her increased availability and regular consultation with residents were noted, in particular. It was also commented that the staff morale and the atmosphere in the home had improved since her return. A round of quality assurance questionnaires were provided to residents and relatives in August prior to the return of the current manager, which she chased up in September. Some of the issues indicated are similar to those raised in the earlier CSCI questionnaires, returned in July. It appears that these issues may relate to the period prior to the return of the current manager, but in order to ensure that no significant concerns remain, a further round of questionnaires, focused on the period since the manager’s return, might be beneficial. Questionnaires were also previously sent to external professionals and care managers, but these were returned to the provider and were not available in the unit for inspection. A copy of the summary report relating to a previous quality assurance cycle, during the tenure of the last manager, was available in the unit, but the summary report for the July QA cycle had yet to be provided to the unit. The provider operates other quality assurance systems, including monthly peer-audit by other home managers in the group, and bi-monthly validation audits by a regional manager. The home scored highly in both recent reports. The provider also fulfils their legal responsibility under Regulation 26 to carry out monthly monitoring visits and provide a report to the manager for action and filing in the unit. It would appear that there is significant overlap in these management processes and there may be opportunities to streamline them. DS0000065501.V305723.R01.S.doc Version 5.2 Page 25 Although there is no overall annual development plan produced for the home, there are monthly business action plans in place, plus monthly training audits, which cover the relevant areas. As noted earlier, the manager plans to re-start regular residents meetings with an informal coffee morning format and attend them herself to obtain direct feedback from residents and relatives who may also attend. She is also planning to consult with them on how to spend the Hollies Residents’ Fund. The home looks after the personal allowance on behalf of many of the residents. Appropriate systems and records were found to be in place to evidence the proper care of these funds, including individual running balance sheets and monthly reconciliation records. The manager holds regular staff meetings, which are minuted, and the staff sign to confirm they have read the minutes. There are also a range of periodic meetings of staff at various levels to enable frank discussion of any issues. Health and safety matters are well managed in the home, with periodic health and safety meetings and regular monitoring in place. Examination of a sample of health and safety-related service certification indicated that periodic checks do take place. Wheelchairs are checked regularly and water temperatures are checked and recorded. As noted earlier, the manager is a qualified Health and Safety officer and trainer. The accident recording system is detailed and appropriate, with collective records being maintained for monitoring as well as the required individual records within case files. There are also monthly monitoring sheets compiled to assist the manager to identify any patterns of concern. These and the collective record are held within a folder and separated by month for clarity, which is good practice. The manager, (correctly), also records all minor falls/rolls from bed within the accident system, in case of subsequent injury, which is good practice and also allows for individual wellbeing and possible health deterioration to be effectively monitored. DS0000065501.V305723.R01.S.doc Version 5.2 Page 26 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000065501.V305723.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP8 OP9 OP15 OP33 Good Practice Recommendations The manager should consider the provision of photographs to accompany the names of designated care staff in each resident’s bedroom. The manager should consider how best to reduce the risk of medication recording errors/omissions. The manager should consider undertaking a further residents’ satisfaction survey around meals issues to establish whether any significant concerns remain. The manager should consider the benefits of a further round of questionnaires to residents/relatives to establish whether any significant concerns remain, about the quality of care provided. (This could include meals as above). DS0000065501.V305723.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford, OX4 2SU 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 DS0000065501.V305723.R01.S.doc Version 5.2 Page 29 - 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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