Inspection on 23/11/06 for Holly Court

This inspection was carried out on 23rd 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

Holly Court 25/09/08

Holly Court 11/02/06

Holly Court 18/10/05

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 Sue Jennings Key Unannounced Inspection 10:00 23rd November 2006 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.V305985.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. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 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 www.schealthcare.co.uk 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.V305985.R01.S.doc Version 5.2 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). 11th February 2006 Date of last inspection Brief Description of the Service: Holly Court is a care home offering personal care only to 25 older people diagnosed 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 accommodation comprises of 25 single en-suite rooms and appropriate communal facilities on two floors. 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. Fees for accommodation at the home are £355.52 to £450.00 per week. Additional costs; Hairdressing, newspapers, toiletries, chiropody and aromatherapy. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 5 hours on Thursday 23rd November 2006. During the course of the site visit time was spent talking to the manager, the operations manager 2 residents a visitor and 2 members of staff to find out their views of the home. The inspector spent time examining records and the residents and staff files. A tour of the building was also made. The requirements from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. During this inspection the key National Minimum Standards were assessed. What the service does well: What has improved since the last inspection? The requirements identified at the previous visit had been met. The home had changed the dispensing pharmacist since the last inspection and staff training had been provided. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 6 Staff were receiving supervision and all staff had been asked to read the home’s policy on physical intervention and have signed to state their understanding of this. 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.V305985.R01.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 Court DS0000008362.V305985.R01.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes admission procedures make sure that residents have sufficient information to make an informed decision about moving into the home. EVIDENCE: A sample of residents’ files was seen. Residents had been provided with a statement of terms and conditions of residence. The home carried out a preadmission assessment to ensure that they were able to meet residents needs. Prior to any admission, risks were assessed to make sure that the home could meet the needs of the prospective resident. There was evidence to demonstrate that relatives were involved with the admission process and the planning of care. A social worker’s assessment of need was available and was held with the resident’s care plan. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 9 Prospective residents were able to visit the home prior to moving in and staff members take this opportunity to meet prospective residents as part of the pre-admission process. This home does not provide intermediate care facilities. Holly Court DS0000008362.V305985.R01.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 good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents were being met by the home. However, there were some concerns regarding the non-administration of medication. EVIDENCE: Residents and their relatives or representatives were being involved in the review of their care plans. Care plans examined were signed by the resident or their representative. It is hoped that this will provide more information about the person for example a past history of the persons life, work, social, and family details. Care plans included risk assessments, and were linked to the initial assessments, making sure that all residents’ identified needs were addressed. Care plans included oral health care, nutrition, continence, mobility and history of falls, religious and cultural needs. The good practice of addressing religious/cultural needs in care plans was noted. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 11 One relative spoken to said that they were encouraged to be part of the care planning process. Minutes of relatives meetings showed evidence that the home tried to include relatives in the planning of care. Relatives and or representatives were asked to read and sign care plans. Senior staff were responsible for internal reviews of care and there was evidence that care plans were regularly reviewed. A relative said, “He is always washed and nicely dressed”. All residents were registered with a general practitioner of their choice wherever possible. The deputy manager monitored appointments and health checks for the residents. One relative said, “They ring and let me know if the doctor has been the staff will do anything to help”. Medication is provided in a Boot blister pack monitored dosage system that is stored securely in a locked room. Each Medication Administration Record (MAR sheets) contained a picture of the resident to reduce the risk of errors in administration. A list of staff responsible for the administration of medication was held on the MAR sheet file and included sample signatures and initials. There were a number of gaps noted on the MAR sheets for one service user where an iron supplement was prescribed for one tablet to be taken twice a day. This medication was actually only being administered by the home in the mornings. The manager was advised to seek medical advice regarding any risk to the resident of not taking the medication. It is acknowledged that the manager and deputy manager said they would speak to staff responsible for administering night medications at the night staff meeting. This meeting was already planned for the evening of the site visit. It was also noted that the MAR sheets contained administration instructions such as “to be taken as directed”. To make sure there are no errors in administration the manager should write to the General Practitioners to request that full administration instructions are provided in line with the Royal Pharmaceutical Society Guidelines. The deputy manager stated that she had contacted the surgery on a number of occasions regarding this issue. It was strongly recommended that the home write to the GP’s responsible. The home provided a separate fridge to store those medicines requiring cold storage. Regular temperature checks were made and the results recorded. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. The home provided a good environment with some activities available. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents EVIDENCE: The activity organiser was on maternity leave and the staff group was carrying out the activities. The only activities noted at the time of the site visit were some of the female residents receiving a manicure from staff and a karaoke style video playing in the lounge. It was noted that one resident was sitting in their room watching a children’s TV programme. The deputy manager stated that this resident watched a particular programme each day and that staff usually changed channels once this had ended. One relative said, “ They do nice things like little parties and day trips. I have been invited to have Christmas lunch here. The staff said they will set a table Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 13 for two so we can eat together. It has been very difficult for me to come to terms with and they have been very supportive”. The meals are prepared and cooked at Laburnum Court, which is situated next door to Holly Court. The meals are then transferred to Holly Court in an industrial style heated trolley. There is a small satellite kitchen in each lounge at the home, stocked with basic supplies such as bread, tea/coffee and milk to enable staff to prepare light snacks and hot drinks for residents. The menu plan for the day was detailed on the notice board displayed in each lounge. The home retained a record of meals served, including supper, to show that choices were available. One relative spoken to said that they had been put in touch with Age Concern who provided some support. A relative said, “He likes his own company and gets agitated in a group. The staff take his meals to his room if that is what he prefers”. The home has a mini bus and this is used to take residents out on trips to places of local interest. Ministers from various faiths visit the home and one resident goes to the local church to attend mass. The home has an open visiting policy and relatives and friends of the residents are able to visit at any time during the day. The residents are able to receive visitors in the privacy of their own rooms or in one of the communal lounges. There are no restrictions on visiting unless the resident has agreed this. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 14 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. The home had policies and procedures that served to protect the residents from abuse. A complaint procedure was available and was known to residents. EVIDENCE: The home had a complaint procedure. No complaints had been received by the Commission in the period since the last inspection. One relative said, “ I have had some minor issues but these have been dealt with quickly by the manager or deputy manager”. The home had an adult protection policy. Staff spoken to were aware of the policy and of the action to be taken in the event of an allegation of abuse. Staff spoken to stated that they had received Protection of Vulnerable Adults training. They appeared to know what action to take in the event of an allegation of abuse being made. A copy of the Salford Adult Protection Policy and Procedure document was displayed at the staff workstation. Examination of training records indicated that the staff received induction training and Protection of Vulnerable Adults training. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for residents with specialist equipment available as required by individual residents. The standard of hygiene was generally well maintained both internally and externally. EVIDENCE: The home was generally clean and odour free, however one of the ground floor bedrooms had an extremely bad odour from the carpet even though the area was regularly cleaned. The odour was present along the ground floor corridor and did not give a good first impression of the home. In order to provide a more pleasant environment for the resident the manager was advised to discuss with relatives the possibility of replacing the bedroom Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 16 carpet with a more suitable type of floor covering. It is acknowledged that the manager and operations manager made arrangements during the site visit for the carpet to be replaced as soon as possible. Toilet doors were painted a bright yellow colour and a picture of a toilet displayed on each door. This made it easier for residents to identify where the toilets were. Bathroom doors were painted blue with a picture of a bath displayed. The decoration both externally and internally was of a good standard and the furniture was domestic in nature giving a homely atmosphere. Residents were seen sitting in various lounges listening to music or watching television and staff nwere present in all areas to meet the needs of the residents. The satellite kitchen on the ground floor and drinks making facilities on the first floor were clean and hygienic. These areas had been stocked with additional provisions to respond to residents’ choices and preferences in the morning. These were restocked on a daily basis and records of the items sent from the main kitchen were kept. Fridge temperatures were monitored along with a record of the schedule of the cleaning of these areas. The laundry is situated in Laburnum Court and a member of staff transfers this in colour coded laundry bags. Soiled laundry is transferred and placed into the washing machines in dispersible red bags. Appropriate arrangements were in place for the disposal of clinical and domestic waste. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures protected residents and staff had the necessary skills and experience to meet the needs of the residents. EVIDENCE: All but two of the staff in the home had achieved NVQ level II and the remaining two were awaiting for a place on the course. Staff who have completed their NVQ training have done a unit covering Equality and Diversity issues. The deputy manager and a member of night staff have achieved NVQ level III. The organisation has two members of staff who are trained as dementia care trainers. Some of the staff had attended a three-day course, ‘Yesterday, Today and Tomorrow’, which is provided by the Alzheimer’s society. The home had a robust recruitment procedure, which ensured that the staff were suitable to work with vulnerable residents. Staff files examined demonstrated that appropriate checks were carried out to protect the residents. There was evidence to show that staff supervision was carried out at regular intervals throughout the year. All staff files sampled had signed contracts on file. All applications were subject to equal opportunities monitoring. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 18 The manager said that about half of the staff at the home had attended dementia care training. As this home specialises in dementia care it is strongly recommended that all staff receive dementia care training. This issue was discussed with the operations manager during the site visit. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The residents’ safety was promoted through appropriate management and administration procedures. EVIDENCE: The manager had been in post for eight years and held NVQ level II, III and the registered managers award. The manager was working towards NVQ level IV. The home has a quality monitoring system. Copies of the forms were displayed in the foyer and forms had been sent to each resident’s relatives but it was reported that none had been returned. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 20 Regular meetings are held with residents, relatives and staff. The facilities manager for the home was carrying out an audit of the home on the day of the site visit. Accidents were recorded in a record book that met the requirements of the DATA Protection Act 1998. Fixed Gas and Electricty appliances had been regularly maintained and a periodic test of portable appliences and lifting equipment had been carried out. Fire drills had been carried out at regular intervals. Staff spoken to were aware of the procedure to be followed in the event of the fire alarm sounding. Hot food temperatures were recorded in the main kitchen at Laburnum Court as were fridge and freezer temperatures. The home is not appointee for any of the residents. The home has policies and procedures in place to manage the finances of the residents. Records kept at the home indicate that the financial interest of the residents is safeguarded. The manager said that in general residents families assisted with finances although they do hold the personal allowances for some residents. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 21 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 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 3 X 3 X 3 X X 3 Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Timescale for action The registered person shall make 30/01/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall 30/01/07 ensure that the care home is conducted so as to keep the care home free from offensive odours. Requirement 2. OP26 16(2)(k) 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 OP9 OP18 Good Practice Recommendations The provider should write to General Practitioners to request that full administration instructions are provided in line with the Royal Pharmaceutical Society Guidelines. The registered provider should ensure that the staff employed to work at the care home receive training appropriate to the work they are to perform. Holly Court DS0000008362.V305985.R01.S.doc Version 5.2 Page 23 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.V305985.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!