Inspection on 18/10/05 for Holly Court

This inspection was carried out on 18th October 2005.

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 Court 25/09/08

Holly Court 23/11/06

Holly Court 11/02/06

Holly Court 31/01/05

Holly Court 16/06/04

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

CARE HOMES FOR OLDER PEOPLE Holly Court 8 Priory Grove Salford Gtr Manchester M7 2HT Lead Inspector Joe Kenny Unannounced Inspection 18th October 2005 07:00 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 Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly Court Address 8 Priory Grove Salford Gtr Manchester M7 2HT 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) 0161 708 0174 Southern Cross Healthcare Services Limited Mrs Brenda McStravick Care Home 25 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (24) of places Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual currently accommodated is below 65 years of age. If this service user leaves, the service user category will revert to DE(E). 31st January 2005 Date of last inspection Brief Description of the Service: Holly Court is a residential care home, registered to accommodate 25 older people with dementia. The home is situated in a residential area of Salford within close walking distance of local community facilities. Holly Court is a purpose built provision owned by Southern Cross Healthcare. The registered manager is Mrs Brenda McStavick. The accommodation comprises of 25 single en-suite rooms and appropriate communal facilities. Catering and laundry are conducted from Laburnum Court, a provision in close proximity to the home and also owned and managed by Southern Cross Healthcare Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the home was carried out unannounced and took place at 07:00 hours. This enabled inspectors to take the opportunity to speak to night staff, staff commencing day care cover and residents awake at that time of the morning. There were three night staff on duty. During discussion with staff it was unclear as to which member of the staff team was designated as senior for the night shift. This matter requires clarification and is detailed in the body of the report. At the time of the inspection there were 25 residents accommodated, 12 on the ground floor and 13 on the first floor. There were 10 residents up at the time of the inspection. The inspection included discussions with residents and staff about their experiences of living and working in the home. A sample selection of records were examined. Systems relating to administration of medication were inspected and a tour of the home was undertaken by inspectors. The inspection only looked at a limited number of standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents living there. What the service does well: The home had reviewed recording procedures for care planning and risk assessments. The review had been carried out to update residents’ care plans and risk assessments. Care is delivered to residents on the ground and first floor level by designated staff. Each level has its own lounge dining room facility and satellite kitchen. A review of staffing arrangement at night had also improved care delivery during the night hours. There are three staff on duty, one member available to staff assigned to ground and first floor level. The staff team offered an appropriate gender mix to residents. Records relating to residents’ were well maintained by staff and evidenced the level of support offered to individuals. The home operated an open policy on visiting times to the home. The plan gave a lot of information about what the residents like; communication and things of importance that the staff needed to know to meet the residents’ needs. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, and 5 Procedure for admission to the home ensures prospective residents and their representatives have the information they need to make an informed decision about moving to the home. EVIDENCE: All residents’ admissions were planned and involved a full assessment of needs being completed. Prior to any admission, risks were assessed to make sure that the home could meet the needs of the prospective resident. Relatives are involved in the admission and continuing care of their relative. The process of providing residents with a statement of terms and conditions of residence had commenced and must be extended to all residents in the home. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, and 10 Residents received support in aspects of personal care, health, and the care of medication. However, the home must ensure all aspects of care are monitored and reviewed to ensure a consistent approach to care. EVIDENCE: The inspection took place at 07.00 hours and a number of residents were already up and dressed. During discussion with these residents it was evident that they had not received a drink, that morning. Staff on duty were busy supporting other residents to get up and confirmed in discussion that they had not prepared residents a drink. The arrangements in the morning should ensure all resident are offered a drink when they get up. All meals are prepared from the main kitchen of the adjoining nursing home, also managed by Southern Cross Health care. The satellite kitchens on each level at Holly Court, did not contain enough essentials to prepare beverages, breakfast or light snacks. One resident was in bed and staff were observed to check on her. The resident did appear to require support to get up but this did not happen until day staff commenced their shift. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 10 The Care plans commenced with a written heading stating that Holly Court was a Nursing Home. The home is not registered as a nursing home and the heading should be revised to ensure it is not misleading to relatives, residents and staff. The home is advised to ensure plans are dated at the time they are drawn up and agreed, and that reviews are held on the scheduled dates recorded on the file. These comments relate to files examined at the time of the inspection. The health of the residents was well recorded and understood by the staff team. Records were kept about all health professionals and GP involvement in the care of the resident. A total of four residents required the assistance of two staff at all times. The medication records were examined. Procedures were in place for recording medication received by the home and returned to the chemist for disposal. Medication records were completed and up to date. The home is advised to ensure plans are dated at the time they are drawn up and agreed, and that reviews are held on the scheduled dates recorded on the file. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Insufficient evidence was retained on the files to record the support offered to residents on daily life and social activities. EVIDENCE: Staff indicated the social and leisure activities take place in the afternoons. There was limited evidence of this and the home must retain information to support this aspect of care. The home does employ an activity organiser, however her hours are shared with Laburnum Court, the adjoining nursing home managed by Southern Cross Health care. The menu plan for the day was detailed on the notice board displayed in each lounge. The home is advised to retain a record of meals served, including supper, in order to demonstrate the choices available. Information did indicate that a Halloween party would be held at the home. There were plans for three residents to go on a break to Blackpool. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 12 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 Procedures relating to complaints and protection were in place that safeguarded residents from abuse. EVIDENCE: Information about the method to make complaints about the home was forwarded to all relatives to address a requirement make at the previous inspection. No complaints had been received by the home or the Commission for Social Care Inspection. From talking with the members of staff on duty, they were aware of the issues of adult protection. The manager stated that training had been provided to staff on the subject. The home is again advised to retain evidence that all staff had read the local authority guidelines on adult protection. The manager described the revised procedures for the safe handling of residents finances and arrangements for its safekeeping. These were agreed as appropriate arrangements, and were checked on the day and found to be in order. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 13 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, 24, 25 and 26 The residents lived in a clean, homely, comfortable and safe environment. EVIDENCE: The home had a comfortable and a pleasant relaxing atmosphere. The lounge and dining areas had been decorated in the period since the last inspection. A tour of the home was completed. The furniture was seen to be in a good condition. On inspection of the small cleaning area for catering arrangements, it was noted that the cups and beakers were heavily stained and required cleaning and/or replacing. The area in general required a comprehensive cleaning The satellite kitchen required stocking with additional provisions to respond to residents’ choices and preferences in the morning. The indications were that the cupboards and fridge are restocked on a daily basis. These facilities must be checked routinely to ensure standards of cleanliness and quantity of provisions meet residents’ needs. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 14 The exit door on the ground floor and the external route leading to Laburnum Court had been replaced to address a requirement at the previous inspection. The arrangement for management of odours in the shower facilities continue to require monitoring and regular flushing of the “U” bend to prevent waste odours entering the facility. Appropriate arrangements were in place for the disposal of clinical and domestic waste. The noticeable odours on corridors appeared to be managed by the home through its domestic cleaning arrangements. Because the satellite kitchen is open plan the home is advised to complete a risk assessment for all residents relating to access of the kettle in the kitchen area. The walls to around the kitchen and sink area required decorating. The home must ensure all window restrictors are functioning to restrict opening. The windows required cleaning on the outside and all external frames. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 15 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 and 29 Programmes of supervision and training must be formalised to support staff and to ensure appropriate skill mix. EVIDENCE: The staff working on nights indicated they had not been instructed or trained in the administration of medication. Consideration should be given to inclusion of night staff on this topic. Staff indicated that supervision is not structured or by appointment. Action should be taken to formalise supervision for night staff. Two care assistants are assigned to the ground floor and two staff to the upper floor cover day hours. These hours do not include the manager’s hours. The staff team were found to be highly motivated and sensitive to the changing needs of residents. However some staff appeared very formal and did not appear to routinely enter into informal chats with resident about every day events. One resident was shouting and there did not appear to be any attempt by staff to engage with the resident. The staffing levels for the period 16 to 22 October 2005 indicated that there were 103 management hours provided and 106 Senior staff hours worked and 170 day care hours. Information relating to training confirmed that up to 10 staff had achieved or were completing the NVQ award. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 16 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): 33, 35 and 38 The residents’ safety was promoted through appropriate management and administration procedures. EVIDENCE: The manager retains responsibility for recruitment and induction of staff. Regular monitoring checks are carried out on the premises. The staff spoken with confirmed they receive verbal and written information on all residents. The records relating to accidents are recorded on the appropriate data protection register. However the reference number was not recorded in sequence, making it difficult to monitor accidents. This issue requires addressing by the home. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 3 2 STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 18 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. 1 Standard OP5 Regulation 5 Requirement The process of providing residents with a statement of terms and conditions of residence must be extended to all residents in the home. The home must ensure all resident are provided with a drink in the morning The home must ensure all satellite kitchens contain enough essentials to prepare beverages, breakfast or light snacks. The Care plans require reviewing to ensure it is not misleading to relatives, residents and staff, where plans refer to Holly Court Nursing Home. The home is not registered as a nursing home. The home is advised to ensure plans are dated at the time they are drawn up and agreed and that reviews are held on the scheduled dates recorded on the file. The home must retain information to support social and leisure activities undertaken at the home. Timescale for action 17/02/06 2 3 OP7 OP7 12 12 17/02/06 17/02/06 4 OP7 12 17/02/06 5 OP9 9 17/02/06 6 OP12 15 17/02/06 Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 19 7 OP15 16 8 OP18 19 9 OP19 23 10 OP19 23 11 OP19 23 12 OP26 23 13 OP27 18 14 OP38 12 The home must retain a record of meals served, to include supper serving in order to demonstrate choice on offer. The home must retain evidence that all staff had read the local authority guidelines on adult protection. Comprehensive cleaning to all areas is needed as is cleaning of the cups and beakers used by residents. The satellite kitchen must be checked routinely to ensure standards of cleanliness and quantity of provisions meet resident’s needs. The management of odours in the shower facilities continue to require monitoring and regular flushing of the “U” bend to prevent waste odours entering the facility is needed. The home must ensure all window restrictors are functioning to restrict opening. The windows required cleaning on the outside and all external frames. Staff indicated that supervision is not structured or by appointment. Action should be taken to formalise supervision for night staff. The records required addressing to ensure reference numbers are recorded in sequence in order to monitor accidents. 17/02/06 17/02/06 17/02/06 17/02/06 17/02/06 17/02/06 17/02/06 17/02/06 Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 20 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 Refer to Standard 7 29 Good Practice Recommendations The home is advised to ensure plans are dated at the time they are drawn up and agreed and that reviews are held on the scheduled dates recorded on the file. Consideration should be given to inclusion of night staff instructed or trained in the administration of medication. Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Holly Court DS0000008362.V259501.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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