Inspection on 19/10/05 for Holly Grange Residential Home

This inspection was carried out on 19th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holly Grange Residential Home 17/03/08

Holly Grange Residential Home 27/03/07

Holly Grange Residential Home 11/05/06

Holly Grange Residential Home 10/05/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Holly Grange Residential Home Cold Ash Hill Cold Ash Thatcham Berkshire RG18 9PT Lead Inspector Marie Carvell Unannounced Inspection 19th October 2005 10:15 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 DS0000062526.V249623.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. DS0000062526.V249623.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly Grange Residential Home Address Cold Ash Hill Cold Ash Thatcham Berkshire RG18 9PT 0118 9410767 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) Mr Sundith Ramdany Mrs Koomari Nanda Ramdany Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places DS0000062526.V249623.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: Holly Grange provides accommodation and care for up to nineteen service users over the sixty five years, who have care needs associated with old age. The home is not registered to provide care to people who have care needs associated with dementia or require nursing care; this would require additional registration categories. DS0000062526.V249623.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by the lead inspector from 10.15am until 3.15pm. Time was spent with the provider/manager, until 1.15pm, staff on duty and the majority of service users. The inspector joined service users for lunch. A tour of the communal areas of the home and some bedrooms at the invitation of the service users were made. A sample of service user, staff and records required to be kept in the home, relating to health, safety and fire were examined. Feedback was given to the provider/manager by telephone two days after the inspection. At the last inspection in May 2005, nineteen requirements were made. Fifteen requirements have been complied with and four remain outstanding, one being partly met, these are that service user plans are generated from a comprehensive assessment, that service user’s psychological health needs and nutritional screening are monitored on a regular basis, that service users are able to exercise personal choice and autonomy and that all staff receive formal supervision from an individual who has received appropriate training. What the service does well: What has improved since the last inspection? It is acknowledged that the manager has complied with fifteen of the requirements made at the last inspection. DS0000062526.V249623.R01.S.doc Version 5.0 Page 6 Communication between the manager and service users has improved and quality assurance systems are being developed to move the outcomes for service users forward. Staffing levels have improved, staff training and supervision has commenced. 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. DS0000062526.V249623.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 DS0000062526.V249623.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 and 5 The home undertakes a pre-admission assessment of new service users to ensure that the home can effectively meet their needs. These standards were subject to requirement at the last inspection. EVIDENCE: Since the last inspection the manager has developed a written admissions procedure. A service user assessment is carried out by the manager and deputy manager prior to admission, which details the service users health, welfare and social circumstances. The manager is currently reviewing the preassessment documentation that is used in the home. Prospective service users and their relatives are given the opportunity to visit the home and to move in on a trial period. DS0000062526.V249623.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): 7,8 and 9 Service user plans contain minimal information and must be developed to enable care staff to provide care based on individual needs. The health care needs of the service users must be developed to include psychological health and nutritional screening. Care staff who administer medication are undertaking a medication administration course. Care staff need training in recording practices. These standards were subject to requirement at the last inspection. EVIDENCE: Service user plans do not contain sufficient information to ensure that all aspects of health, personal and social care needs of the service user are met. The sample of service user plans examined were not routinely updated as the needs of the service user changes, although each month the plan of care is signed and dated as “no change”, when it is evident that the needs of the service user has changed. Service user daily records do not validate service user plans, entries such as “quiet day” or “slept well” are unhelpful and do not evidence care provided. Service users are not involved in their plan of care or their wishes recorded. DS0000062526.V249623.R01.S.doc Version 5.0 Page 10 Care staff who administer medication are undertaking appropriate training. One member of staff has declined the training, this is recorded and the individual does not carry out this task. Service users were seen to be well groomed and appropriately dressed. Staff were observed to be attentive and respectful to service users. DS0000062526.V249623.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 14 A range of activities are available in the home. Choices and preferences for the more dependent service users are not recorded. These standards were subject to requirement at the last inspection. EVIDENCE: Service user meeting now take place on a two monthly basis. Service users requested more activities to be provided in the home. The inspector was informed by service users that bingo has commenced every Friday, music sessions, board games and exercise tapes, twice per week. Some activities are service user lead. The mobile library visits the home monthly, service users are able to have a weekly manicure and a hairdresser visits several times per week. The home had a garden party in the summer and several service users had been on an outing organised by Help the Aged. Choices and preferences for the more dependent service users are not recorded in service user plans and this is left to the discretion of care staff. DS0000062526.V249623.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 Complaints are taken seriously by the manager, are fully investigated with written outcomes. Service users are protected from abuse by the homes policies and procedures. These standards were subject to requirement at the last inspection. EVIDENCE: Since the last inspection the home has received four complaints, these were appropriately recorded with action taken and outcomes. The complaint recording also included a follow up discussion between the manager and service user, several weeks later to ensure that the complaint continues to be satisfactorily addressed. This is considered good practice. All staff have received training in the protection of vulnerable adults from abuse and the home has a copy of the multi-agency procedures. DS0000062526.V249623.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): 22,23,24 and 26 The home provides safe, comfortable and spacious accommodation for the service users. Service users are able to make a positive choice about who they share a double occupancy bedroom with and whether to have a appropriate lock fitted to their bedroom door. These standards were subject to requirement at the last inspection. EVIDENCE: Since the last inspection an Occupational Therapist has carried out an assessment of the premises and facilities, some recommendations were made; the manager is addressing these. The Occupational Therapist’s report confirmed, “Service users have the specialist equipment they require to maximise their independence”. It is evidenced that service users are able to make a positive choice about who they share a double occupancy bedroom with and whether they wish to have an appropriate lock fitted to their bedroom door. This information is recorded. DS0000062526.V249623.R01.S.doc Version 5.0 Page 14 The laundry room has been redecorated and has a tiled floor, which is impermeable. One of the two commercial washing machines has a sluice facility, there is a tumble drier and a double sink installed with hand washing facilities. DS0000062526.V249623.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): 27,29 and 30 Staffing levels are sufficient to meet the needs of the service users. Recruitment procedures have been developed to ensure the protection of service users. These standards were subject to requirement at the last inspection. Staff training is being developed. EVIDENCE: There appeared to be sufficient staff on duty to meet the needs of the service users. From examination of the duty rosters there is generally three staff on duty throughout the day, with one awake care assistant and one care assistant sleeping in on the premises at night. The manager confirmed that he has developed recruitment procedures, however, no new staff have been recruited since the last inspection. This will be followed up at the next inspection. Since the last inspection, some staff training has been provided including fire safety, protection of vulnerable adults from abuse, medication administration and the deputy manager has undertaken supervisory skills training. The manager is currently developing a staff training and development programme. DS0000062526.V249623.R01.S.doc Version 5.0 Page 16 DS0000062526.V249623.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36,37 and 38 The manager is now managing the home more effectively. The home is being run in the best interests of service users. Systems are in place to protect service users financial interests. Staff supervision has commenced. Standards 32,36,37 and 38 were subject to requirements at the last inspection. EVIDENCE: The manager is now rostered to work in the home full time. Service users, staff on duty and the homes duty rosters evidenced this. Service users said that the manager was approachable, had introduced service user meetings, was happy to chat and was generally more responsive. Members of staff felt that communication had improved, but the manager still communicated with the deputy manager, who then cascaded information to staff on duty. Monthly reports on the conduct of the home, written by the second provider of the home, following an unannounced visit are not being sent to the CSCI as required by regulation. DS0000062526.V249623.R01.S.doc Version 5.0 Page 18 Since the last inspection two staff meetings have taken place. Staff felt that meetings are held without any prior arrangements and therefore many staff had not attended any meetings. Both staff meeting minutes stated “ all staff on duty” and had taken place from 1.30pm until 2.00pm. The manager has recently sent out a questionnaire to service users, relatives, healthcare professionals and individuals who regular contact service with service users. It is the manager’s intention to use the feedback to develop services in the home. Financial records are well maintained with written records for the one service user that the home assists. The manager and deputy manager have now completed supervisory training. Staff supervision has recently commenced. Staff have not received an annual appraisal. Policies and procedures need to be reviewed. A sample of records required to be kept in the home were examined. Accident records were appropriately completed. The home’s fire risk assessment carried out in 2003, needs to be updated. The home’s health and safety policy needs to be updated. No fire records were available for examination by the inspector. DS0000062526.V249623.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x x 3 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 2 3 x 3 2 2 2 DS0000062526.V249623.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes four 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 OP7 Regulation 15 Requirement That the manager ensures that service user plans are generated from a comprehensive assessment. Previous timescale of 10/09/05 not met. That the manager ensures that the service users’ psychological health needs and nutritional screening is monitored on a regular basis. Previous timescale of 10/09/05 not met. That the manager advises the CSCI of action taken to ensure that service users are able to exercise personal choice and autonomy. Previous timescale of10/07/05 not met. That the manager completes a staff training and development programme. A copy is to be sent to the CSCI. That a report is written on the conduct of the home, following an unannounced visit by the second provider of the home on a monthly basis. That all care staff receive formal DS0000062526.V249623.R01.S.doc Timescale for action 19/12/05 2 OP8 13 19/12/05 3 OP14 12 19/12/05 4 OP30 18 19/12/05 5 OP32 26 19/11/05 6 OP36 18 19/11/05 Page 21 Version 5.0 7 OP37 17 8 OP38 17 supervision six times per year, e.g. every two months. That the manager ensures that all records required by regulation are up to date, well maintained and accurate. That the manager advises the CSCI whether all fire safety records are up to date and available for examination, that the fire risk assessment for the home is updated and the health and safety policy is updated. 19/11/05 19/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000062526.V249623.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000062526.V249623.R01.S.doc Version 5.0 Page 23 - 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!