Inspection on 27/04/07 for Holly House

This inspection was carried out on 27th April 2007.

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 House 09/05/08

Holly House 29/10/07

Holly House 17/11/05

Holly House 24/03/05

Holly House 12/07/04

Holly House 09/02/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Holly House 124 High Street Burringham Scunthorpe North Lincolnshire DN17 3LY Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 27th April 2007 09:30 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 House DS0000002887.V337819.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 House DS0000002887.V337819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly House Address 124 High Street Burringham Scunthorpe North Lincolnshire DN17 3LY 01724 782351 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) PB Residential Care Limited Position Vacant Care Home 49 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (49) of places Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The bedroom in the cottage with the ensuite bathroom must only be used for service users in the category of OP. Nominated staff to be allocated for each area - Trent House, Holly House and the Cottage and this to be indicated on staff rotas with staffing levels assessed under Residential Forum guidelines 17th November 2005 Date of last inspection Brief Description of the Service: Holly House is situated in the centre of the village of Burringham close to Scunthorpe and local transport links. The home had consisted of three separate buildings known as Holly House, The Cottage and Trent House. The addition of a conservatory linked the Cottage and Holly House. An extension linked Holly House to Trent House forming a dining room, meeting room, reception area, kitchen and office. The older parts of the property had accommodation over two floors. A mechanical stair climber has been provided in The Cottage and Holly House to assist service users with the stairs. The accommodation at Trent House was purpose built and on one level. The home is registered to accommodate 48 male and female service users in the category of old age and including up to 47 service users with dementia. It is a condition of registration that service users with dementia must not be accommodated in the bedroom in Cottage with a bath in the ensuite. Attractive secure garden areas were provided for service users. At the time of the inspection fees at the home were £344 - £388. Additional charges included Chiropody £8, Hairdresser £5 -£10, Escort duty £15 and Newspapers variable. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in April 2007. To find out how the home was run and if the people who lived there were pleased with the care they received the inspector spent time in the home watching how the care was given. The inspector spoke to 7 people who lived in the home and were able to answer some questions about the home, and 2 relatives. The inspector also spent time with other people who were not able to say much about the care they got or how the home was run but were able to say if they were happy at the home. The inspector also spoke to 4 staff that were on duty at the time of the inspection and the manager and one of the providers. As the provider had not returned the pre inspection questionnaire within the timescales required staff, relative and service users questionnaires had to be given out on the first day of the inspection. At the time of writing the report 3 service users and 2 staff surveys had been returned. Any further comments received will be kept on file and used to inform the next inspection. Records kept in the home was also seen, this was to make sure checks that staff were safe to work in the home were completed before they started and that they had been trained to their job safely. Records were checked to make sure that the home and the equipment used in it were safe and were checked regularly. The home had had one complaint prior to the inspection one of which had resulted in a safeguarding adults investigation, which was partially founded. A police investigation, instigated by the provider, in relation to possible financial irregularities was ongoing at the time of the inspection. What the service does well: The home provides a wide variety of communal space and different places to sit. The gardens were attractive and secure, and accessible to the service users. Garden furniture and raised flowerbeds had been provided for the residents to use. The residents said that the staff were good and were kind and polite to them Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 6 Residents were encouraged to do things for themselves where they were able. The service users relatives and staff thought the new manager was approachable and proactive. Staff including the cook had a good understanding of the service users needs and their preferences and these were recorded in the care plans. What has improved since the last inspection? What they could do better: They must provide service users with all the information they need to make an informed choice about the home including a fully completed contract/statement of terms and conditions that sets out the fees and room to be occupied. They must make sure that all service users have a care plan developed which sets out how their assessed needs are to be met. They must ensure that these are kept up to date through regular reviews. They must ensure service users health is monitored, care is provided as planned and monitoring records are completed so that service users nutritional status and tissue viability are maintained. They must make sure that medications are given as prescribed, recorded adequately, and stored at correct temperatures. They must make sure that staff respect service users privacy and dignity at all times particularly when entering service users bedrooms. They must ensure that service users have adequate choice in the meals provided. They must provide activities for the service users that are appropriate to their interests and abilities. They must put systems in place to improve recruitment, training and supervision and staff morale so that the service users are protected, the staff can meet service users needs and work safely. They must make sure that there is adequate staff on duty on every shift to meet the needs of the service users and keep a full record of who is at work in Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 7 the home at any one time. They must ensure that staff can communicate with service users in their first language and are dressed appropriately. They must improve systems to ensure that the home is clean, safe and well maintained. They must improve management monitoring to ensure that the home is run in the best interests of the service users and the quality of the care is improved. 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. The summary of this inspection report can be made available in other formats on request. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users were provided with detailed information about the home. Contracts/statements of terms and conditions had been provided to some service users but the information relating to individual details had not always been fully completed. All service users had had their needs assessed usually before moving into the home. EVIDENCE: The home had a detailed statement of purpose and service users guide, which gave information about the services provided. The documents had been updated but now require further updating to show the management changes. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 10 A selection of four contracts/terms and condition were provided for inspection. The manager stated that contracts were on the process of being updated with the new providers details. The four seen provided detailed information about the services and outlined conditions of residency. Not all the contracts seen had been fully completed. One did not state the fee to be paid or the bedroom to be occupied and one had not been signed. There was evidence in these files that the service users were advised in writing that the home could meet their needs although not all were fully completed and signed. The service users were able to have the first six weeks as a trial visit and this was documented in the contracts/statement of terms and conditions. There was evidence in the care files examined that all the service users had had detailed assessments of their care needs completed usually prior to being offered a place at the home. The file of a service user admitted two weeks before the inspection was also examined. An assessment had been completed on admission, basic care needs, likes and dislikes and preferences had been identified and recorded although a care plan had not been completed to show how needs would be met. The social services assessment and care plan had been obtained. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users health and personal care needs were met and were mostly recorded in well-developed care plans. There was some evidence that systems and records had not been maintained more recently which may affect the quality of care in the longer term if not addressed. Service users were enabled to self medicate if they wished. There were deficiencies in medication processes that may put service users health and welfare at risk. Service users felt they were treated with respect and their privacy was not always upheld. EVIDENCE: Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 12 A random selection of care plans was examined. The care plans were generally very detailed and well organised. One care plan had not been developed from an assessment completed two weeks prior to the inspection. The care plans were generally evaluated monthly with detailed recording but not all the care plans had been updated as needs had changed. There was little evidence that care plans been formally reviewed since 2005. However the manager stated that all the care plans had been the reviewed in March with social services. It is recommended that reviews be completed by the home at least 6 monthly. There was appropriate use of risk assessments particularly for service users at risk of wandering and falls. Although there were risk assessments and care plans in place for those at risk of developing pressure sores and there was some evidence that staff had provided regular care in day although these were completed retrospectively at the end of the shift but there were few records that showed that night staff had provided regular pressure relief. Records showed appropriate and timely referrals for district nurse input and it was recorded that pressure sores had healed or were making good progress towards healing in the care plans seen. Details regarding the service users dietary needs were recorded on assessment and the information was provided to the cooks. Basic nutritional screening and care plans were completed in all but one of the files seen. Records of diet and fluid intake and out put were recorded where there were concerns however these were not always maintained by the night staff and therefore did not provide an accurate record. The care plans showed that service users had generally been weighed monthly but some had not been weighed for the two months prior to the inspection. Appropriate scales were available for service users who were unable to weight bear. Records of contact with GPs and other medical professionals were well maintained and detailed. A policy and procedure for the safe handling of medication was available in the home. Service users were enabled to self medicate if they wished and one service user was self-medicating eye drops. Medication was supplied mostly in a monitored dosage system and two senior staff members were responsible for the medication processes. Clear records for recording receipt of medication and disposal of medication were held and medication was marked with a start date where medication was supplied in a bottle or packet. At the last inspection there were some issues regarding controlling the temperature in the storage facilities for medication due to the very warm weather. At that time the previous manager stated that air conditioning units were to be purchased there was no evidence of this and records of the Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 13 temperature of the room and the drug fridge were not being recorded even though forms and thermometers had been provided. The manager and some of the staff responsible for medication in the home had completed an accredited distance-learning course in the safe handling of medication. There were some concerns from staff that at least two of the senior staff responsible for administering medication had not received this training. An action plan received in relation to a previous complaint stated that medication training was to be provided in February 2007 but this could not be accurately verified, as training records were not up to date. Records of controlled drugs in the home were not being adequately maintained; one staff member stated that this was because they had not been able to obtain a controlled drugs record book. The records did not show a running total and records of administration were not recorded in a bound book and did not show the time of administration. Where one-service user was prescribed a controlled drug to be given every 72 hours and even though the record sheet was clearly marked when this was due this had been given 24 hours late. There were some omissions of signatures or codes in the administration records mainly for the application of prescribed creams. There was evidence from observation and service users comments that staff did not always respect their privacy when entering bedrooms by knocking on doors before entering. The service users felt that their privacy and dignity was respected during care tasks, however one service user who required assistance with care tasks was seen to be wearing dirty trousers and no socks. Staff used service users preferred term of address and this was recorded on care plans. Service users and relatives stated staff were polite and kind when addressing them. Observation of staff interaction with the service users confirmed this. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users generally enjoyed living at the home but found that there was a lack of activities available in the home. Staff were not proactive in this area. Service users were offered choice in daily routines but experienced a lack of choice in the meals provided. The service users were enabled to maintain contact with relatives and friends as they wished. EVIDENCE: Service users were able to choose daily routines and how care was to be delivered. Preferences were recorded in care plans and information regarding likes and dislikes were provided to cooks. Staff were observed to have a good understanding of service users likes and dislikes. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 15 Although social interests were recorded in care plans there was little evidence of regular activities in the home and service users, relatives and staff confirmed this. Staff were not proactive at involving service users in meaningful activities or providing a stimulating environment and stated that they had little time to organise activities. Religious services were held in the home fortnightly. Information regarding arrangements for maintaining contact with relatives and friends was included in the service users guided and statement of purpose. Service users had access to private space to receive visitors either in their own rooms or the training/meeting room. The service users were able to choose whom they wished to see and with only one point of access to the home this could be easily managed. Service users stated that they enjoyed the meals provided but stated that there was a lack of choice. Menus were available but were not followed, menus showed there was only one main choice at lunch but individuals could request an alternative. These were not always recorded. Vegetarian diets and diabetic diets were catered for but were not included on the menus and were not always recorded. Meals observed were well presented and appropriate for the service users dietary needs. Staff were seen to assist service users sensitively and encouragement and supervision was provided where required. One staff member was observed feeding two service users at the same time, which does not allow the individual attention, required for this task. One relative thought that meal times were rushed and that service users were not given sufficient time to eat there meals. This was not evident during the inspection. The service users could choose where they took their meals and the majority ate in the spacious and well planned dining room where there was a lively and cheerful atmosphere. This gave the opportunity for service users from both units to meet and socialise together. Although the service users did not raise any concerns there were no drinks available in communal areas, unless individually requested, outside the normal tea rounds and in only a few instances had service users been provided with drinks in their bedrooms. The manager stated that she would make sure that there were jugs of drinks available. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures were in place to ensure that complaints were taken seriously and acted upon. There were some systems in place to ensure that service users were protected from abuse although there was lack of refresher training in this area and some deficiencies in staff recruitment, which may put service users at risk. EVIDENCE: The home had a detailed complaints procedure, which was displayed in the home and was also contained in information provided to service users. The home had received one complaint since the last inspection with regard to allegations of abuse in the home. The company referred the complaint to the Safeguarding adult’s team in Scunthorpe and an investigation had been completed and partially founded. The company had provided an action plan to address the recommendations by the investigators. The provider had also recently referred some issues to the police involving service users finances and this was under investigation art the time of the inspection. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 17 There was evidence that safeguarding adults training was provided as one of the first elements in the induction process. However whilst there had been a training in this area up to 2005 there had been no refresher training since that time. There was no overview of training to assess how many of the staff in total had received training in this area. There were deficiencies in staff recruitment that may put service users at risk. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 25 and 26 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a marked deterioration in the cleanliness and maintenance of the home that may affect the service users health and safety and compromise fire safety and infection control. EVIDENCE: Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 19 The home had undergone extensive refurbishment and offered spacious and homely accommodation. There were a number of communal areas available for the service users including a smoke room and very spacious dining area. The gardens were attractive, safe and secure and accessible to service users. A tour of the building was completed and it was disappointing to note that there was a marked deterioration in the cleanliness and maintenance of the home. Although the home was reasonably clean and tidy, five bedrooms were found to malodorous. The home was not protected from the spread of fire, as some fire doors were wedged open, some fire doors were not all closing fully on release and linen cupboard doors were not locked. Service users in four adjoining bedrooms in the middle area of the home had no hot water in their ensuites, radiators were not working and they had been supplied with free standing electric radiators which were not guarded and did not have low surface temperatures putting service users at potential risk of accidental scalds. There were no risk assessments in place for their use and the Commission had not been informed of these problems. The use of shared handtowels and bars of soap in communal toilets were compromising infection control in the home and some commodes in bedrooms were rusty so were unable to be adequately cleaned. The bathroom with a hoist in Holly unit had broken and was awaiting repair, service users had been offered the use of the bathroom with a hoist in the Trent unit or a full bed bath. The handrail in one toilet on the Trent unit was loose and wall tiles were missing. The staff were cleaning commode pots in the bathrooms and due to the risk of cross infection the proprietor should consider providing alternative facilities. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels had not been achieved on all shifts, which may leave service users at risk of needs not being met. Staff morale was low. There were deficiencies in staff recruitment, which may put service users at risk. Staff training had not been provided to meet mandatory and service user specific requirements, which may put service users risk. EVIDENCE: Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 21 The Commission had received two anonymous concerns about poor staffing levels in the home just prior to the inspection. Staff rotas had been requested and these showed adequate staff on duty but there had been many changes to the rota and recorded only first names of staff in some instances. One staff member who was new to the home had been counted in staff numbers after just one day shadowing other staff. The pre inspection questionnaire indicated that the homes staffing levels were assessed under the residential forum guidelines. The rotas for a two week period up to the inspection showed that there was adequate staffing with six carers on duty during the day and 4 on duty at night except for two day shifts and one night shift where the staffing had been short by one. Staff stated that they were very busy particularly in the mornings and confirmed that there had been shifts were they had been short. They stated that staff from the providers other homes and agencies had been used to support the staffing in the home. The information provided in the pre inspection questionnaire and the proprietor supported these comments. The staff morale in the home was reported to be low due to recent changes. Service users and relatives had noticed the changes and expressed some concerns especially where temporary staff had worn inappropriate clothing and jewellery and where staff were not able to adequately communicate as English was not their first language. The service users said that the permanent staff were ‘very good’, and ‘very nice’. The pre inspection questionnaire stated that 18 of the 30 care staff had achieved at least NVQ 2. However training records were not up to date and there had been some changes in the staff group so the accuracy of this statement could not be verified. Some of the staff spoken with had achieved NVQ Qualifications. Examination of four staff files that had commenced employment since the last inspection showed that there were some deficiencies in obtaining all the information and checks required prior to employment, In one case there was no evidence that identity had been checked, in another there were no references and in another only one written reference had been obtained and one telephone reference had been recorded. The newly appointed manager, who had been transferred from another home owned by the provider, had only a standard Criminal Records Bureau (CRB) check on file dated 2004. There was little evidence that mandatory or service user specific training had continued to be provided at regular intervals since the last inspection. There was no training plan in place and there was no overview of training. Staff confirmed that there had been no training in the last year. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 22 There was evidence that induction training had been provided using common induction standards work books for recent starters. The plan included safeguarding adults and moving and handling training in the first sessions. The induction also included some shifts where new staff shadowed other staff and were extra to the required numbers on the shift. However due to recent staffing problems one new member of staff had commenced on shift with no induction and as part of the numbers. The carer was experienced and had achieved NVQ. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There had been management changes and a new but experienced person was managing the home although not all the pre-employment checks for this person had been completed. Changes had affected staff morale. Although there was a system to monitor the quality of the service this had not been implemented and so the home is not being run in the best interest of the service users. Service users finances may not have been appropriately managed and the provider has instigated a police investigation. Staff had not received regular formal supervision. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 24 The health and safety of the service users and the staff may be compromised due to deficiencies in the environment, staff training, safety checks and recording. There was a lack of monitoring by the providers. EVIDENCE: The previous manager had left at the end of March 2007 and Linda Blackburn had been employed in this role since the 10 April 2007. Linda stated that she has worked in a deputy manager’s position for the past eighteen months and had worked in care fro many years prior to this. She was able to provide evidence of her training to date and this showed that she had achieved a wide range of training in relevant areas including the Registered Managers Award an NVQ 2 and 3. The staff reported that morale was low due to recent changes. There was no evidence of any meetings held in the home since August 2006, the staff and the provider stated that meetings had been held but they hadn’t made any records of these. Although staff felt there had been some positive changes they felt they were not encouraged to make comments to the providers if they had any issues and where they had these had not been well received. Staff service users and visitors alike thought the new manager was proactive and approachable. Although the Regulation 26 reports stated that the manager and staff were working well with the quality assurance programme and there was a process for measuring the quality of the care received in the home there was no evidence this had been implemented. Although there has been some management monitoring of the home the deficiencies found in records and processes indicate that this was not effective. There were some detailed policies and procedures but these had not been made specific to the home, although there was some evidence that work had been commenced with this. The provider stated that work was ongoing to bring some standardisation of policies and procedures across all his homes. Some of the service users finances were being managed by the home but were not checked as they were under police investigation at the time of the inspection. The provider had instigated the investigation. There was little evidence that staff had received regular formal supervision recently and this had been spasmodic during 2006 with no evidence that the standard of six times a year had been achieved. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 25 The management of health and safety had not been fully maintained Mandatory training had not been provided, including moving and handling and fire safety, since the last inspection. Records showed that weekly fire alarm and monthly emergency lighting tests had been completed up until January 2007 but then not again until the day of the inspection. Monthly tests of emergency lights had not been completed since December 2006. The home was not protected from the spread of fire, as some fire doors were wedged open, some fire doors were not all closing fully on release and linen cupboard doors were not locked. Service users in four adjoining bedrooms in the middle area of the home had no hot water in their ensuites, radiators were not working and they had been supplied with free standing electric radiators which were not guarded and did not have low surface temperatures putting service users at potential risk of accidental scalds. There were no risk assessments in place for their use and the Commission had not been informed of these problems. There was evidence that other equipment safety checks had been completed as required. Accident records were seen and detailed records of hospital visits or medical assistance had been maintained. However where concerns were raised in relation to one fall the accident record could not be located although records were held in other parts of the care file. The incident was under investigation by the provider in relation to a staff conduct issue and a report was requested into this. The passenger lift to the Cottage area had recently been broken and taken a week to repair. Concerns were raised that the providers and staff had carried a service user up the stairs in a wheelchair and assisted another service user who had difficulty mobilising to climb the stairs putting all at risk of harm. The proprietor was advised that this practise was unsafe and must mot be repeated. The proprietor and the service user stated a room on the ground floor had been offered but the service user had declined. Materials hazardous to health had been left so they were easily accessible to service users. Cleaning cupboards had been left unlocked and service users had been provided with denture cleaning tablets in their rooms. Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X 2 X X 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X X 2 X 1 Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP2 Regulation 5(1)(b)(c) Requirement The registered person must ensure that all service users receive a contract/statement of terms and conditions that sets out the fee to be paid and the room to be occupied so that they have adequate information to make and informed choice about the home. The registered person must ensure that all service users have a care plan developed which sets out how their assessed needs are to be met. They must ensure that these are kept up to date through regular reviews. The registered person must ensure service users health is monitored, care is provided as planned and monitoring records are completed so that service users nutritional status and tissue viability are maintained. The registered person must provide running totals of controlled drugs in a bound record book, ensure that medications are administered as DS0000002887.V337819.R01.S.doc Timescale for action 01/07/07 2. OP7 15 01/07/07 3 OP8 13(4)(c) 01/06/07 4 OP9 13(2) 01/06/07 Holly House Version 5.2 Page 28 5 OP10 12(4)(a) 6 OP12 16(2)(m)( n) 7 OP15 16(2)(i) 12(2) 17(2) 8 OP18 13(6) prescribed and that records of administration are maintained, that medication is stored at the correct temperatures and staff have received accredited training. Evidence of staff training must be provided to the Commission. This is to ensure service users have medication prescribed and the safe handling and storage of medications. The registered person must ensure that staff always knock on service users doors before entering the bedrooms and ensure that service users are appropriately dressed so that service users privacy and dignity are protected. The registered person must ensure that an activities plan is developed with the service users taking into account their interests and abilities so that service users have the opportunity to be involved in meaningful activities of their choice and within their capabilities. The registered person must develop menus which offer choice and take into account service users likes, dislikes and dietary requirements so that service users nutritional needs are met service users are able to exercise choice at meal times. Copies of the menus must be sent to the Commission. Records of food served must be maintained so that the Commission can make a judgement as the quality and choice of food served. The registered person must provide evidence to the Commission that all staff have received training and updates at DS0000002887.V337819.R01.S.doc 01/06/07 01/07/07 01/07/07 01/07/07 Holly House Version 5.2 Page 29 9 OP19 23(4) 10 OP22 23(2) 11 OP25 23(2) 13(4) 12 OP25 23(2) 13(3) 13 OP26 13(3) 14 OP26 16(k) 15 OP27 18(1)(a) regular intervals in safeguarding adults from abuse to ensure that service users are adequately protected. The registered person must ensure that fire doors are not wedged open and close fully on release, linen cupboard doors must be kept locked to minimise the risk and spread of fire in the home. The registered person must ensure that repairs to the toilet handrail and tiles, bath hoist on Holly unit are completed to ensure that service users needs are safely met. The registered person must ensure that radiators in all bedrooms are working and these and any supplementary heat sources are guarded or have low surface temperatures to promote service users comfort and minimize the risk of scalds. The registered person must ensure that there is hot water close to but not exceeding 43°C in service users ensuites to promote service users comfort and minimise the risk of spread of infection. The registered person must provide individual soap and towels in communal areas and ensure that commodes can be adequately cleaned to minimise the risk of the spread of infection. The registered person must ensure that the home is kept free from offensive odours to ensure a comfortable environment for the service users. The registered person must ensure that at least minimum staffing levels are maintained at DS0000002887.V337819.R01.S.doc 27/04/07 01/06/07 01/06/07 01/06/07 01/06/07 01/07/07 27/04/07 Holly House Version 5.2 Page 30 16 OP27 18(1)(b) 17 OP29 19 17 OP30 18(1) 13(4) 13(5) 18 OP30 18(1) 19 OP31 9(2) 20 OP32 12(5)(a) all times as per Residential Forum Guidance and full records of staff on duty are maintained to ensure service users needs are met and provide evidence of staff levels. The registered person must ensure that staff are able to communicate with service users in their first language and are dressed appropriately for their role to ensure service users needs are met and to promote health and safety in the work place. The registered person must ensure that all employment checks as per Schedule 2 of the Care Home Regulations 2001 are completed prior to staff commencing work in the home to protect the service users. The registered person must provide a training plan to the Commission, which sets out how mandatory and service user specific training is to be provided so that care to meet service users needs can be provided safely. The registered person must ensure that management systems are developed to ensure that mandatory training is kept up to date. (Previous timescale 30/01/06 not met) The registered person must provide evidence that a Criminal Records Bureau enhanced check has been completed for the new manager to protect the service users. The registered person must ensure that the management approach of the home creates an open, positive an inclusive atmosphere to raise staff moral DS0000002887.V337819.R01.S.doc 27/04/07 27/04/07 01/06/07 01/06/07 01/07/07 27/04/07 Holly House Version 5.2 Page 31 21 OP33 24 22 OP36 18(2) 23 OP38 23(4) 24 OP38 37 25 OP38 13(4) 26 OP38 13(4) and assist in staff retention. The registered person must implement the quality assurance and management monitoring systems in the home to improve the quality of the service provided and ensure that the home is run in the best interests of the service users. Regulation 26 reports to be provided to the Commission until further notice. The registered person must ensure that staff receive regular formal supervision at least six times a year to ensure that staff are supported, policies and procedures are put into practise and service users needs are met. The registered person must ensure that fire alarms are tested weekly and emergency lights are tested monthly to protect service users in the event of the a fire and to minimise spread of fire in the home. The registered person must provide a report following the investigation regarding the fall of a service user and staff conduct issue to ensure that actions have been taken in relation to the incident. The registered person must ensure that alternative arrangements have been agreed with service users in first floor rooms and systems are in place to support service users when the passenger lift is not in working order to ensure their health and safety is maintained The registered person must ensure that materials hazardous to health are stored securely to protect service users. 01/07/07 01/07/07 27/04/07 01/06/07 01/06/07 27/04/07 Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 32 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 OP7 OP26 Good Practice Recommendations The registered person should ensure that care packages are formally reviewed 6 monthly with all interested parties. The registered person should provide alternative facilities to clean commode pots other than bathrooms Holly House DS0000002887.V337819.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 House DS0000002887.V337819.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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