Inspection on 24/07/06 for Holly Bank Care Home

This inspection was carried out on 24th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Holly Bank Care Home 21/11/07

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 HOMES FOR OLDER PEOPLE Holly Bank Care Home 70 Manchester Road Heywood Rochdale Lancashire OL10 2AW Lead Inspector Diane Gaunt Key Unannounced Inspection 24 July 2006 09:00 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 Holly Bank Care Home DS0000066359.V298171.R02.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. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Bank Care Home Address 70 Manchester Road Heywood Rochdale Lancashire OL10 2AW 01706 623388 F/P 01706 623388 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) None Eagle Care Homes Ltd Mrs Monica Yvonne Narnor Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 38 service users to include: up to 38 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager who is registered with the CSCI. N/A Date of last inspection Brief Description of the Service: Holly Bank is a large detached house standing in its own grounds. It has been extended to provide accommodation for 38 older people, providing personal care for all. Thirty-eight single rooms are provided, 34 of which are en suite. The home is situated in a residential area on the outskirts of Heywood and is on a main bus route. A local shop and Post Office are situated nearby and there is a public bowling green to the side of the home. Ramped access is provided to the rear and both sides of the home. The area outside the conservatory has been landscaped to provide a large patio with a water feature. Car parking is available to the front and side of the home. The most recent Commission for Social Care Inspection (CSCI) report was available in the entrance area. At the time of this inspection weekly fees were £331.42p per week, approximately £1436 per month. Additional charges were for hairdressing, chiropody, toiletries and newspapers. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written using information held on CSCI records and information provided by people who live at Holly Bank, their relatives, professionals who visit the home, the manager and staff at the home. A site visit to Holly Bank on 24 July 2006 took place over 11¾ hours. The home had not been told beforehand when the inspector would visit. The inspector looked around the building and looked at paperwork that had to be kept to show that the home is being run properly. To find out more about the home the inspector spoke with six residents, three visitors, two senior carers, three carers, the cook, two domestics, the manager, the operations manager and one of the directors of Eagle Care Homes Ltd who is registered with the CSCI as the Responsible Individual. Questionnaires/comment cards asking residents, relatives and professional visitors what they thought about the care at Holly Bank had been given out a few weeks before the inspection. Two residents, two relatives, District Nurses and a GP filled them in and returned them to the CSCI. What the service does well: What has improved since the last inspection? Since being registered as owners of Holly Bank, Eagle Care Homes Ltd had undertaken a full audit of the building, health and safety and care issues. They had begun to address areas identified in their audit and improvements were seen in the decoration of some communal areas and bedrooms. Gardens and pathways had also been improved and work was ongoing. An action plan addressing outstanding areas had been given to the manager for her attention. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 6 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. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents were assessed before they moved in to ensure the home could meet their needs but written information about the home or terms and conditions of their stay were not issued prior to admission to help them decide if they wanted to live there. EVIDENCE: An updated Statement of Purpose/Service User Guide had been written by Eagle Care Homes Ltd but had not been given to residents. Copies of the Statement of Purpose/Service User Guide written by the previous owner were available in every bedroom and provided some relevant information about the home. However, due to the change of ownership, some of the information was inaccurate. Eagle Care Home Ltd contracts and/terms and conditions had not been issued to residents, although Social Services Department Service Delivery Agreements were in place for all residents whose care they funded. Individual records were kept for each resident. Three files were inspected and all had assessments completed by the manager prior to admission. If Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 9 residents were funded by the Social Services Department a care management assessment was also completed. The manager visited people in their home or hospital settings in order to assess them. Records showed that the assessment covered not only assessment of need but other important areas such as culture and religion, with a note made of people’s wishes in these and other personal choice areas. Whilst in each instance the assessments indicated Holly Bank could meet the residents’ needs, one resident who was 64 years of was admitted to the home without application for variation of registration being made. The home is not registered to care for people under 65 years of age. This resident no longer lives at the home. The manager did not visit to assess people who needed to move in an emergency but the home reserved the right to ask the person to find an alternative placement if they could not meet their needs. One resident who had just moved into the home for a short stay was satisfied with the assessment and admission processes at the home, they had stayed at Holly Bank a number of times in the past so was familiar with the home on this admission. Two others returning questionnaires considered they received sufficient information about the home before moving in, although they did not say how long ago they moved in. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although residents and relatives reported that personal and healthcare needs were met, they were not always fully recorded, neither were they discussed with residents and/or relatives, leaving residents at risk of not having their needs met. Procedures were in place to facilitate the safe handling of medicines, and whilst most practices were satisfactory, some were in need of improvement to ensure safe administration. EVIDENCE: At the time of this visit a new care plan format was being introduced. Three care plans were inspected, two related to residents who had moved in within the previous 6 weeks, the other was in relation to a resident who had lived at the home for a longer period. A complete plan of care was in place for the most recently admitted resident but the other two had not been fully completed. As previous care plans were no longer available to staff they did not have written guidance in some areas of care for these residents and where standard formats had been used, individual amendments had not been added to fully describe the care the person needed e.g. mouth care of a frail resident; Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 11 the effect of a resident’s pain on moving and handling; what specific help was needed with hygiene needs. Risk assessments relating to falls, skin care, nutrition and moving and handling were written but were not always dated making it difficult to assess when they were completed or whether they were due for review. One care plan recorded a risk assessment relating to wandering which was completed over 2 months prior to the inspection visit. Although the resident was no longer able to mobilise this risk assessment had not been amended. Care plans had not been written or reviewed with residents and their relatives prior to the change of ownership and new care plan formats were being completed without consultation. Eagle Care Homes Ltd have a policy of monthly reviews and the operations manager said that these reviews would include residents and relatives. Evidence of the consultation and their involvement should be recorded on file. A care manager had held a review with one resident four days prior to the inspection. This was noted on the care plan and the home awaited a report from the care manager. Despite relevant information not being recorded, staff spoken with were aware of residents needs. Two returned residents questionnaires said that the care and support needed was always provided, and 2 relatives returning comments cards were satisfied with the care given at the home. Residents all appeared clean and well cared for. One relative commented that since the health of the resident they visited had deteriorated staff had ‘given first class attention, advice, care and consideration to myself & other family members’. However, two other relatives considered staff did not sufficiently encourage and monitor resident’s fluid intake during the hot weather. One resident supported this view and said that she ‘needed goading’ into drinking more and staff were not doing this. On the day of the inspection site visit residents had not been offered a drink between breakfast and dinner-time and were seen to have dry mouths when eating their dinner. Residents and staff said that this was unusual and was as a result of the inspector meeting with residents when midmorning drinks should have been served. However, the matter was raised with the manager and staff by the inspector both prior to and during lunch. Both a hot and cold drink were then offered with the dessert and gratefully received by residents. The manager and staff all said that they were aware of Department of Health heat-wave advice and regularly offered and encouraged residents to drink. This was not supported by observation and feedback from those interviewed. There was evidence on file that health care professionals were consulted as necessary and a record made of advice given during their visits. A GP and District Nurses returning comment cards said they were satisfied with the overall care at the home. Two returned resident questionnaires said the medical support required was always provided. Evidence was seen of the implementation of the dietician’s advice with regard to one frail resident who Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 12 required regular monitoring of food/fluid intake and positional changes in bed. District Nurses were attending two residents with pressure sores and suitable equipment was in use for both recovery from and prevention of pressure sores. District Nurses and GP returning comments cards considered staff communicated clearly and worked in partnership with them with staff demonstrating a clear understanding of the care needs of the service users. The activities co-ordinator was mindful of the need to encourage exercise and records showed that armchair exercises were offered regularly as were games which involved movement e.g. skittles, darts. Staff said they played music for residents and occasionally got them up to dance. Observation showed that staff spoke to residents in manner which respected their dignity. All residents had single rooms and the majority had en suite rooms which enhanced their privacy and dignity. Locks were provided to bedroom doors but were problematic in that they automatically shut when doors were closed. Lockable space was provided in most, but not all occupied rooms. Visitors were able to see residents in their own rooms or in communal areas and the GP and District Nurses said they were able to see their patients in private. Eagle Care Homes Ltd policies and procedures describing medicines handling had been introduced but the home was working to the previous procedures. Arrangements for the receipt of weekly medication from the chemist was satisfactory in that the amount received was counted, recorded and signed for. Receipt of the medication of a resident receiving respite care was handwritten onto the medication administration records and whilst the record was signed, it was not countersigned. When the medication was checked against administration records the number of tablets remaining did not match in 3 out of 4 instances. This may have resulted from an error of administration, counting or recording medication received. When medication administration records of another resident were checked they did not clearly record when and why the medication had not been given. A code ‘other’ was used on some occasions but no note had been as what ‘other’ referred to. In one instance the inspector was advised the tablet had been administered but the resident had not swallowed it, this was not recorded. Medicines were administered by senior staff, all of whom had received accredited training. The manager said there were plans for staff to take an NVQ in medication management. The home supported self-administration and one resident chose to selfadminister their medication. A signed agreement with the resident regarding this arrangement was held on file. The agreement referred to a risk Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 13 assessment having been undertaken by the manager but there was no paper work to support this statement. Separate records of controlled drug handling were satisfactorily maintained. Medicines for disposal were regularly returned to the pharmacist and satisfactory records of this process were maintained. Medication was stored securely. A separate secure controlled drugs cupboard was provided and medications securely stored in a locked trolley within the locked medicines room. A drugs fridge was provided and the temperature monitored on a daily basis. These temperatures should be recorded. Holly Bank Care Home DS0000066359.V298171.R02.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 and 15 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Residents were encouraged to exercise choice in their daily routines and to maintain contact with relatives and local churches, although some did not go out into the local community as often as they would like. Meals offered both choice and variety and action was being taken to further meet residents wishes. EVIDENCE: A social activities organiser worked at the home for approximately 1½ hours each weekday. A formal programme was not used but the organiser kept a daily record of activities. The inspector observed residents taking part in a skittles session in the conservatory. Everyone was encouraged to participate and the organiser’s enthusiasm was infectious. The activities diary included art work completed by residents, showing talent which they had not previously known they had. Other activities offered included quizzes, crosswords, games, reading the Heywood Advertiser out loud for everyone, manicure, music and movement, drawing, arts and crafts and bingo. In addition to this care staff played cards and dominoes or chatted with residents. The organiser had also taken one resident out shopping. Discussion with her indicated she knew the residents well and was aware of their social needs from spending time with them. She was not actively involved in care planning, the manager may wish Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 15 to encourage her to work with key workers when completing social care plans so that information is shared and used to plan future activities. One resident completing a questionnaire considered that activities provided were sometimes suitable; a relative considered residents were bored when the activities had finished. Another relative said they would appreciate the activities organiser spending time with residents who stayed in their rooms. Residents who attended a meeting at the beginning of July had discussed activities but did not suggest any changes to the in-house programme. They did say they would like trips out to local shops and theatres, arrangements had not been made although the manager said they would be. This was identified as an area to develop on the manager’s action plan. Residents sometimes enjoyed sitting outside on the patio in good weather but found the weather too hot on the day of the inspection visit. Two residents said they enjoyed the view from the conservatory, another said they liked to watch the bowling at the club behind the home. Plans to provide level access in order to make the gardens more accessible to residents were underway. The religious needs of the resident group were being met. The manager established faith needs on admission and representatives of the Church of England and Roman Catholic churches attended the home to provide communion to those who wished to take it. The inspector was informed other arrangements would be made as required and a notice to this effect was dispayed on the notice board in the entrance area. Relatives said they were made to feel welcome by staff and were kept informed when their relative was ill or any changes to their condition were identified. On the day of inspection some residents chose to see relatives in the comfort of their own rooms whilst other chose to meet in the communal lounges. Residents said they were able to make choices during their day and were seen to come and go as they wished in the home. Minutes of a residents meeting showed that they were encouraged to express their views and alter things they were not happy with through the meeting. Seating arrangements had been changed at the home to provide two lounge/dining rooms but residents had not been happy with the arrangement. Staff said that when this was raised with them they made changes to meet residents wishes. Those returning questionnaires said that staff listened to and acted upon what they said. Residents spoken with said they generally enjoyed the food served at the home and said they had a choice. Those who sat in the conservatory said that it was sometimes not hot enough when it was served and one person who sat in the other lounge/diner said they sometimes had to wait a while for the meal to be served when they had been assisted to the table. Both these comments were shared with the operations manager who said he would address them. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 16 The inspector stayed for lunch and observed a choice of steak and kidney pudding or cod in sauce, chips and peas. Residents had been asked for their choice of meal by care staff earlier in the morning. It was a very hot day and the food was hot enough when served, it was also tasty. Only one dessert was offered at lunchtime (fruit salad) and although staff said an alternative of ice cream would be available if needed it was not offered to residents. A choice of desserts should be available and offered to residents. Four weekly menus were in place, the cook said they were due for review. At a recent meeting residents had requested more variety at tea time i.e. jacket potatoes, salads. The cook had begun to introduce these on an individual basis but had not yet incorporated them into the menu. Fruit was occasionally cut up and served to residents mid-morning. The operations manager advised that Eagle Care Homes Ltd had menus which they intended to introduce and these included more healthy options. . The special dietary needs of the residents were being met. Four residents required diabetic diets and the cook prepared desserts which they could also enjoy. Four residents required liquidised diets and each food item was prepared separately to ensure the taste, colour and texture remained the same. One staff member was observed assisting a resident with lunch and did so in a sensitive and encouraging way. Holly Bank Care Home DS0000066359.V298171.R02.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 and 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 knew who to go to with concerns and complaints and issues raised were addressed. Appropriate systems were in place to protect residents from abuse, and staff were familiar with alerting procedures which they used to keep residents safe. EVIDENCE: The home had a complaints procedure. It was on the notice board in the entrance area and a copy was available in each bedroom. Residents and relatives returning questionnaires/comment cards knew who to speak to if they had complaints or concerns. Those spoken with said the manager was available for them to speak to whenever she was in the home and that she dealt with matters raised with her. A complaints log was kept and three entries had been made since the last inspection. The complaints were substantiated and speedy action taken by the manager to address matters raised. A relative who had written to senior management at the home to raise a concern said her letter was not acknowledged – although the matter was addressed. The complaint log did not record receipt of the letter. CSCI had not received any complaints since the change of ownership. A whistle blowing procedure was available as was a copy of Rochdale Social Services Department’s Inter-agency protection procedure. Staff spoken with Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 18 understood the importance of reporting malpractice. Nine staff had attended external Protection of Vulnerable Adult (POVA) training provided by Rochdale Social Services Department, and a further four were booked onto the course. The operations manager had taken appropriate action when alerted to an allegation protection issue which was reported and investigated satisfactorily following internal and external policies and procedures. Staff were not employed at the home until necessary checks had been taken. Feedback from residents indicated they felt safe living at Holly Bank. Holly Bank Care Home DS0000066359.V298171.R02.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, 20, 24, and 26 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The decor and furnishings were being improved to create more comfortable surroundings for residents and the home was clean in the main. Infection control practices were satisfactory. EVIDENCE: The environment was in need of improvement when Eagle Care Homes Ltd bought the home four months prior to this visit and since registration the new owners had prioritised work on improving the environment. A lounge/dining room and ground floor corridor had been decorated as had a number of bedrooms and a ground floor lounge which was not yet in use. The ground floor corridor carpet had been cleaned and eleven new easy chairs purchased. Outside, the front door had been painted, the front garden cleared and tubs of flowers provided to the front of the house. Work to level the pathway to the rear of the building was ongoing at the time of this visit. The residents and relatives spoken with were aware work was being undertaken to improve the building. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 20 The operational manager had audited the building in order to establish priorities which included replacement of a number of carpet. A tour of the building with the manager and operations manager identified a number of smaller areas also in need of attention e.g. provision of lockable space, repair to wash hand basin units in bedrooms, replacement of stained ceiling tiles, worn enamel on two baths. A maintenance and renewal plan had not been written at the time of the visit, it was agreed these items would be included in it. Most of the bedrooms looked at were bright, airy and personalised with residents personal belongings bringing a homely touch to their rooms. A resident who had come for a short stay had also brought in some small items to make them feel more at home during their stay. Locks were fitted to bedroom doors but these were not safety locks. Consequently, when bedroom doors were closed staff needed a key to open them. Residents said they could get around the home fairly easily and observation supported this view. Appropriate aids and adaptations were fitted in bathrooms, toilets and corridors so that residents could remain as independent as possible. Two lounge/dining rooms were provided and although residents had initially been allocated seating areas there had been changes to accommodate their wishes. A choice of assisted bathrooms were provided on both floors although a shower was not provided. Those spoken with and returing questionnaires considered the home was generally kept fresh and clean. Observation supported this view, although on the afternoon of this visit there were a minority of occupied and unoccupied rooms which were in need of further cleaning and one room had an unpleasant odour. The odour was confined to the room, the operations manager said he would ensure the matter was attended to when next the domestic staff were on duty. Residents spoke well of the domestic staff who they were seen to have positive relationships with. Infection control policies/procedures were in place. Although not all staff had recived this training, staff spoken with during the inspection were clear as to basic safe infection control practices. They said that suitable gloves and aprons were always available for them. Liquid soap and paper towels were supplied in toilets and bathrooms. Adequate laundry facilities were in place and individual baskets were supplied for each resident’s clothes. Residents and relatives spoken with said that a satisfactory service was provided and clothes were washed and returned as required. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 21 Greater Manchester Fire Officers had inspected the home in June and the company were working to address their requirements. These will be followed up by GM Fire Officers in September 2006. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were protected by the home’s recruitment and selection practices and staff were trained and competent to do their jobs. EVIDENCE: Inspection of three weeks rotas showed that sufficient staff were provided to meet residents’ needs. Although some staff had left the home since the change of ownership, the experienced core staff group remained and new carers had been recruited. Residents spoke positively about the staff, one person described them as ‘wonderful’ and another as ‘smashing’ and one resident spoke well of the new carers. A relative completing a questionnaire said she had ‘been impressed with friendliness and care of all staff’. Inspection of three staff files provided evidence that in-house induction training which met national standards was provided but not always completed within the recommended timescale. The manager was in the process of making arrangements to supplement the induction with a local learn direct course which would address the matter. Eagle Care Homes Ltd were also planning to introduce the company’s induction programme which addressed Skills for Care common induction standards along with additional information. Two of the most recently recruited staff considered their induction met their needs. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 23 A training matrix was held at the home but was not up to date. An amended matrix forwarded to CSCI after the inspection visit provided conflicting information in some instances. However, the matrix indicated that of 25 care staff, 16 had completed NVQ level 2 or NVQ level 3. Other training which a minority of staff had attended included communication skills, managing aggression, loss and bereavement, palliative care and medication management. A dementia care course run by an Alzheimer’s Society trainer had begun at the home, senior management and almost all the staff group had attended. Staff spoke positively of the training and were looking forward to the remaining session. Health and safety training had not been kept up to date during the previous ownership. Eagle Care Homes Ltd were addressing the matter and staff had been booked onto a range of health and safety courses, although more courses were needed to ensure each person had updated training. Further comment is made in the management and administration section below. Staff files inspected provided evidence of good recruitment practice. Two satisfactory references, POVA 1st (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) checks were taken prior to employment. Staff were in the process of negotiating new contracts with Eagle Care Homes Ltd whilst continuing to work under the conditions of their previous employer. Prior to signing contracts staff were required to read and agree to a number of Eagle Care Homes Ltd policies which included health and safety issues, supervision and confidentiality. A number of staff said they found the time available to them to read these policies was insufficient for them to absorb the detail. Senior managers may wish to consider ways of extending the time staff have to read and understand before signing their agreement. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 24 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, and 38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Management of the home was in need of improvement in order for duties to be fully discharged. The home had a number of quality assurance systems which sought residents’ views and these were being further developed. Residents’ financial interests were safeguarded and, with the exception of sufficient up to date health and safety training for staff, the health, safety and welfare of residents was protected. EVIDENCE: The manager of the home had been registered with the CSCI for just over 18 months. She is a trained nurse and at the time of the inspection site visit had almost completed the Registered Manager’s Award. Since Eagle Care Homes Ltd became owners of Holly Bank, one of the company directors and the operations manager had taken on some of the management function whilst also auditing the home. Following the audit an action plan had been prepared Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 25 for the manager to assist her in fulfilling her duties. The manager had been working on the plan for 2 weeks but a number of issues had not been addressed within timescale e.g. medication management and keeping of an accurate, up to date training matrix. This inspection visit showed they had not been achieved. Staff on duty on the day of the inspection visit had concerns about morale. Discussion with the representative of Eagle Care Homes Ltd. indicated that this was a result of the change in ownership. A number of quality assurance systems were in place e.g. 3 monthly staff meetings, resident meetings which were to be held monthly, staff supervision, circulation of questionnaires to residents/relatives. Questionnaires had been circulated in April and July, at the time of the inspection site visit responses had not been collated. The operations director said it was his intention to collate responses and address matters. The responsible individual had written a business plan and an action plan had been written for the manager to address in order to improve the quality of the service. Eagle Care Homes Ltd had introduced company policies and procedures which in some instances were running alongside the home’s previous policies and procedures. Although Regulation 26 visit reports had not been written, the responsible individual and operations manager had fulfilled the functions of these visits as evidenced in their action plans. As the audit process is now complete the operations manager planned to begin monthly visits which would be recorded for monitoring purposes. Eagle Care Homes Ltd did not act as appointee for any residents. In the main relatives or solicitors assisted residents in the management of their finances. Two residents managed their own money. Some relatives chose to leave small amounts of money in the home’s safekeeping. This was held securely and all incomings and outgoings recorded. Records and monies held in respect of two residents were inspected and seen to be in order. As stated above, health and safety training had not been kept up to date prior to Eagle Care Homes Ltd ownership. The training matrix provided showed that there were still a significant number of staff who had not completed up to date moving and handling, food hygiene, and infection control training. Whilst the majority of senior staff had attended 1st Aid training, rotas showed there were some shifts when a trained 1st Aider was not on duty. All kitchen staff had attended certificated food hygiene training. Maintenance records were inspected and seen to be in order and COSHH risk assessments were written. Fire precaution checks were undertaken regularly but not all staff had attended a fire practice or lecture within the last 12 months. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 26 A large radiator was seen to be uncovered. As the weather was very hot at the time of the inspection it was not on. It was agreed it would be disabled until a cover was provided. This work should be included in the maintenance plan. Accidents were appropriately recorded and satisfactory action taken Eagle Care Homes Ltd had commissioned a full health and safety audit of the home shortly prior to this inspection visit and were planning to action items raised. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 27 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 1 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 2 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 2 X 2 X 3 X X 2 Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation 4&5 Requirement An up to date Statement of Purpose and Service User Guide must be made available to prospective and current residents to include terms and conditions of their stay. Copies must also be provided to CSCI. Residents and/or relatives must be consulted when care plans are written and reviewed to ensure they include accurate, individual and agreed interventions to meet their needs. The registered person must regularly audit the management of medication to make sure medicines are given correctly and that accurate records of medication handling are maintained. The registered person must ensure that there is written assessment of safe selfadministration. Timescale for action 31/08/06 2 OP7 15 30/09/06 3 OP9 17(3)(a) 14/08/06 4 OP9 12(1)(b) 14/08/06 Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 29 5 OP19 16 A maintenance and renewal plan addressing each identified area for improvement and including projected timescales must be written and a copy forwarded to the Commission for Social Care Inspection. Sufficient staff should have 1st aid training to ensure one trained person per shift is on duty. All care staff must receive up to date health and safety training including moving and handling, food hygiene and infection control. All staff must attend a fire lecture and fire drill/practice at least once per year. 31/08/06 6 OP38 13 30/09/06 7 OP38 13 31/10/06 8 OP38 23 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP2 OP8 OP9 OP24 Good Practice Recommendations Residents should be issued with Eagle Care Homes Ltd contracts and/terms and conditions of their stay. Department of Health heat wave guidance should be followed and staff ensure that residents are given sufficient fluid every day, not just during the heat wave. Handwritten entries on medication records should be checked, signed and countersigned. Safety locks should be fitted to bedroom and doors and residents issued with a key unless risk assessment indicates otherwise. Holly Bank Care Home DS0000066359.V298171.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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