Inspection on 29/10/07 for Holly House

This inspection was carried out on 29th October 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 27/04/07

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 29th October 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.V354692.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.V354692.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) hollyhouse5@aol.com 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.V354692.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 27th April 2007 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. A lift in the Cottage is amore recent addition. The accommodation at Trent House was purpose built and on one level. The home is registered to accommodate 49 male and female service users in the category of old age and including up to 48 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 £340.83 - £405 per week. Additional charges included Chiropody, Hairdresser, Escort duty and Newspapers. Holly House DS0000002887.V354692.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 three days in October/November 2007. To find out how the home was run and if the people who lived there were pleased with the care they received time was spent in the home watching how the care was given. The inspector spoke to 10 people who lived in the home and were able to answer some questions about the home and a relative. Time was also spent 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. We spoke to staff that were on duty at the time of the inspection, four were interviewed formally and the administrator. We also spoke to the manager, area manager and the manager form another home who was supporting the new manager. The previous manager provided information about the home prior to the inspection. During the course of the inspection it became apparent that this had been copied from a document provided by one of the providers other homes and for the main part did not reflect the services provided by Holly House. Surveys were sent for staff and people living in the home to complete and provide their comments on the quality of the care provided. There was a poor response to these and only three people who lived in the home and three staff had returned theirs. Two surveys were received from health professionals who visited the home. 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 do their job safely. Records were checked to make sure that the home and the equipment used in it was safe and checked regularly. There had been two management changes since the last inspection and the new manager James Wade had only started work in the home the week before the inspection. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 7 The providers must provide more effective management of the home to ensure that the quality of the care is improved and the home can be further developed. 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 provide activities for the service users that are appropriate to their interests and abilities. They must put systems in place to improve training specific to people’s needs and supervision so that the service users are protected, the staff can meet service users needs and work safely. They must improve systems to ensure that the home is clean, safe and well maintained. 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.V354692.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.V354692.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, Standard 6 is not applicable to this service. People who use the service experience adequate 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 but the had not been updated as changes occurred. Contracts/statements of terms and conditions had been provided to service users. 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 in September 2006 but still required further updating to show the management changes since this time. In surveys people confirmed they had received information about the home which had enabled them to make an informed choice. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 10 A selection of three contracts/terms and conditions were examined. The three seen provided detailed information about the services and outlined conditions of residency. 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 manager or another member of the senior staff completed these. Eight care files were examined and all contained assessments of need although these were not always dated when they had been completed. One staff member stated “we were not given details of a new client for three weeks until I asked for them from the office”. Four other staff confirmed that senior staff complete the assessments before people arrive in the home and information as to the individual’s needs is provided to the care staff prior to admission. Holly House DS0000002887.V354692.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 poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The majority of peoples health and personal care needs were recorded in care plans. However there was evidence that systems and records had not been maintained consistently and health had not always been adequately monitored and some people’s needs were not adequately met. 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 upheld. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 12 EVIDENCE: A random selection of nine care plans was examined. The care plans were generally very detailed and well organised. There was some evidence that care plans had been reviewed in 2007 although this had not been applied across the service in a planned way. It is recommended that reviews be completed by the home at least 6 monthly. The care plans were generally evaluated monthly although one hadn’t been evaluated since the person’s admission in June 2007 and others hadn’t been evaluated since August 2007. The evaluations showed little evidence of linking to other monitoring forms such as weight charts or records of challenging behaviour or wandering. The care plans had not always been updated as needs had changed. For example one person had been nursed in bed fro at least two months since they had become immobile butt eh care plan had not been updated to show the change in care requirements. Risk assessments relating to mobility, use of bedrails and risk of pressure sores had not been had not been completed or where they were in place they had not been updated. Details regarding the service users dietary needs were recorded on assessment and the information was provided to the cooks. The care plans showed that service users had generally been weighed monthly. Appropriate scales were available for service users who were unable to weight bear. There was evidence that where a person had had weight loss this had been recorded and referred to the GP in a timely manner. However there was some evidence where people’s health needs in this area had not been met. In one case weight loss had been recorded but there was little evidence of any action being taken to address this in the records. The care plan had not been developed to show how this person was to be supported when taking meals even though they had difficulty due to a medical condition. On observation at meal times they were not appropriately assisted and aids had not been provided to ensure independence could be maintained and an adequate diet taken. This was reported to the manager and a referral to the dietician for advice was made by the third day of the inspection and the care plan had been updated. In another case an instruction to be weighed weekly because of issues relating to weight loss had not been followed. A health professional on a survey stated that the home is “not always seeking advice until the person has further deteriorated, quite often leaves problems to become worse before acting”. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 13 Action had been taken to ensure the safety of one person who had wandered from the home on several occasions and was now cared for in a secure area. However a risk assessment had not been completed and an action plan developed to minimise the risks of wandering. There was some indication that action had been taken to reduce the risks at night and this was recorded on the care plan. The information provided prior to the inspection stated that there was no one being cared for in the home who developed a pressure sore. Staff interviewed confirmed this. The care plans identified where people may be at risk of pressure sores due to poor mobility. Risk assessments were also completed although these had not always been reviewed and updated. Staff showed an awareness of the care required to minimise the risk of pressure sores. The district nursing service had provided pressure-relieving aids. A policy and procedure for the safe handling of medication was available in the home. People 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. 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 previous inspections there were some issues regarding control of the temperature in the storage facilities for medication. Records of the temperature of the room and the drug fridge were not being recorded daily even though forms and thermometers had been provided and there was little evidence of action being taken to address the issues raised. By the third day of the inspection the medication storage had been moved to a larger room where the temperature could be more easily controlled however this still requires monitoring. The staff responsible for medication in the home had completed an accredited distance-learning course in the safe handling of medication. However the record keeping in the home with regard to medication was poor. Records of controlled drugs in the home were not being adequately maintained. Although a controlled drug register had been obtained there were gaps in the recording and records were not always accurate. The records did not show when medication had been returned to people when they returned home. There were also several omissions of signatures or codes in the administration records of other medications. Observation of a medication round at lunchtime showed the staff to be frequently disturbed during the process of administering medication due to the dependency of the people during meal times. There was a high risk or error during this time and may be a factor in the poor record keeping. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 14 By the third day of the inspection staff had been provided with a safe handling of medication update. The manager had liaised with the pharmacist and medication administration times had been changed to reduce the risk of error at meal times. There was evidence from observation and people’s comments that staff respect privacy when entering bedrooms by knocking on doors before entering. People felt that their privacy and dignity was respected during care tasks. Staff used preferred term of address and this was recorded on care plans. Observation of staff interaction with the service users confirmed that there was good communication with people who lived in the home. There was a lively and homely feel in the home; a relative said the staff “create a homely, welcome environment”. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 15 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 outcomes in this area. This judgement has been made using available evidence including a visit to this service. People generally enjoyed living at the home and the meals provided but found that there was a lack of activities available in the home. People were enabled to maintain contact with relatives and friends as they wished. EVIDENCE: People 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. Although social interests were recorded in care plans there was little evidence in records of regular activities in the home. Surveys from people who lived in the home; relatives, a health professional and staff confirmed this. There was Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 16 no formal plan to involve people in meaningful activities or to provide a stimulating environment and staff stated that they had little time to organise activities. During the inspection staff were seen to be involving people in games and generally there was a lively atmosphere. This interaction was not recorded. Religious services were held in the home fortnightly, services were held in the large dining room and staff stated that there was a good attendance rate. A lady also visited the home fortnightly to provide motivational activities with people from both areas in the home. This included exercises, games, singing and dancing. People stated that they enjoyed this. Information regarding arrangements for maintaining contact with relatives and friends was included in the service users’ guide and statement of purpose. There was access to private space to receive visitors either in their own rooms or the training/meeting room. People were able to choose whom they wished to see and with only one point of access to the home this could be easily managed. People who lived in the home stated that they enjoyed the meals provided, they said the food “is very good”, and “choices are offered”. One relative who ate with their relative stated the food was “very good”. Menus were available and showed there was a choice at breakfast, lunch and tea and individuals could also request an alternative to the menu if required. Vegetarian diets and diabetic diets were catered for. Meals observed were well presented and appropriate for the service users’ dietary needs. Differing portion sizes were provided. However very small potions of meat were served to all on the third day of the inspection. The cook did not know how much meat needed to be prepared per person to provide an adequate nutritional intake of this food group. Staff were seen to assist service users sensitively. However there was a high number of people who required assistance with meals. At least seven people in the dining room and others in bedrooms needed feeding and a number of other’s required supervision and prompting. Staff were observed feeding two service users at the same time, which does not allow the individual attention required for this task. Staff who were administering medication were being frequently interrupted in an attempt to supervise and prompt people to eat. Overall there was an air of chaos in the dining room and people were not receiving the attention required to take an adequate diet. By the third day of the inspection the home had changed the times of the medication round following discussion with the pharmacist. This had enabled all the staff to concentrate on assisting people at meal times and the atmosphere was much improved. The impact of medication round changes will need to be monitored. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 17 People could choose where they took their meals and the majority ate in the spacious and well planned dining room. This gave the opportunity for people from both units to meet and socialise together. Although people did not raise any concerns there were no drinks available in communal areas, unless individually requested, outside the normal tea rounds. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 18 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 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 although records were not available for all complaints received by the home. There were systems in place to ensure that people were protected from abuse. EVIDENCE: The home had a detailed complaints procedure, which was displayed in the home and was also contained in information about the home and the services provided. The home had received three complaints since the last inspection. The records for one of the complaints were complete and showed the action taken in response to the complaint. Records for the other two complaints were not available in the home; the manager stated that was because the area manager was dealing with these. There was evidence that safeguarding adults training was provided as one of the first elements in the induction process. The manager stated that all staff Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 19 had received refresher training in this area in July 2007 but certificates had not been received from the providers of the training. We contacted the training provider following the inspection and it was confirmed that they visited the home on three occasions in August 2007 and provided training to the staff in safeguarding adults. There had been no concerns, complaints or allegations regarding the home or the care provided made to the Commission since the last inspection. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 20 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, 21, 24, 25 and 26. People who use the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a continued deterioration in the maintenance of the home that may affect the service users health and safety and compromise fire safety. The cleanliness of the home had improved. EVIDENCE: The home offered spacious and homely accommodation. There were a number of communal areas available for people including a smoke room and very spacious dining area. The gardens were attractive, safe, secure and accessible. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 21 The staff stated that there the system for reporting repairs works well and items are attended to quickly. From the issues raised during the tour of building this would not support this comment. A tour of the building was completed and it was disappointing to note that there was a continued deterioration in the maintenance of the home. The home was much cleaner and tidier than at the last visit. but the lounges in the Trent unit were odorous. The home was not protected from the spread of fire, some fire doors were not closing fully on release and linen cupboard doors were not locked. There were continuing problems with provision of hot water in some bedrooms in the middle of the home. The manager stated that there was ongoing work to try and resolve these problems. Issues with radiators had been resolved and there were no free standing radiators being used in the home at the time of the inspection. The use of shared hand towels and bars of soap in communal toilets, which was compromising infection control in the home at the ast inspection, had been addressed. Soap dispensers and paper towels had been provided. It was confirmed that new commodes were on order, these had arrived by the third day of the inspection. Since the last inspection a new bath with a hoist had been fitted in Holly unit and repairs had been completed in the bathroom in Trent unit. The staff were still cleaning commode pots in the bathroom on Holly unit but a sluice had now been provided for one area of the home. The following issues were raised from the tour of the building at this inspection, which need to be addressed: Cleaning cupboard doors not locked giving people who live in the home access to substances hazardous to health. Laundry cupboard doors not locked and room 27 door was not closing fully, which does not protect the home from the spread of fire. Toilet seats in the majority of the toilets in the home were broken. Not all the double rooms in Trent unit had a privacy screen. Although these were not shared at the time of the inspection they will need to be replaced before a second person is admitted to the room. The blind in the conservatory was broken and blinds in the dinning room were falling down. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There were significant improvements in all areas relating to staff recruitment and training since the last inspection and as a result staff morale had improved. Extension of the training programme with regard to the specific needs of people living in the home will improve the care provided. EVIDENCE: Although the management stated that rotas had been planned using residential forum guidelines there was no evidence of this. However the rotas for a twoweek 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. Although one person had commented on survey, “I think you need more staff”. Staff stated that staffing levels had improved over the past few weeks. They stated that staff from the providers other homes had been used to support the staffing in the home if there were gaps in the rotas. They said that the providers would always try and get cover. Staff confirmed that new staff had been appointed recently. The rotas showed where new members of staff were supernumerary on rotas as part of their induction. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 23 The staff morale in the home had improved. Staff said the staff morale was “not too bad”. James Wade is the home’s fourth manger since April 2007 and the staff said of the new manager, “James is really good and puts staff at ease”. The people spoken with in the inspection all said the staff were “very good”. The pre inspection information provided by the home stated that 17 of the 36 care staff had achieved at least NVQ 2. However staff records were poorly maintained 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 adequate checks had been completed although some information was not readily at hand it was produced by the end of the inspection. The new manager’s file could not be checked as manager’s records were held centrally. There was evidence that mandatory training had been provided since the last inspection. This training included moving and handling, safeguarding adults, infection control and food hygiene. There was a training plan in place and there was an overview of training. Staff confirmed that there had been training in the last year in a variety of subjects. The manager was to attend a course in training staff in dementia care and then this would be provided to staff. Further training at Grantham college was also to be made available to staff. Training in areas specific to the needs of the people staff care for must also be provided. 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 rotas and comments from staff evidenced that induction also included some shifts where new staff shadowed other staff and were extra to the required numbers on the shift. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 People who use the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. There have been four managers in the home in 2007 and the home had not had a registered manager since April 2007. This had adversely affected the quality of the service provided and put people who lived in the home at risk. There has been little significant improvement since the last inspection indicating that there was a lack of effective monitoring and support by the providers through this period of management instability. People had been consulted on the quality of care in the home but the system to monitor the quality of the service had not been fully implemented and progress to improve standards had been slow. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 25 The home’s policies and procedures had not been fully implemented and staff had not received formal supervision so people’s health safety and welfare had not been safeguarded. The health and safety of the service users and the staff may be compromised due to deficiencies in the environment, safety checks and recording. EVIDENCE: The person in the manager’s position at the last inspection had left and a new manager had been appointed in August but had left in the week prior to the inspection. The new manager James Wade stated that he had been in the care industry for seventeen years and had worked in a senior care position prior to coming into this management position. He stated he had gained NVQ 3 in care and was registered to commence the Registered Managers Award in January 2008. He stated he had completed other mandatory training but recognised that he would require further training for this role in areas such as supervision and health and safety. Mr Wade’s employment history and training could not be verified, as his file was not available for inspection. The manager was being supported in his role by another manager form a sister home and the area manager. The staff reported that morale had improved and although it was very early days they found the new manager approachable. However formal recorded staff supervision was not being provided. Although there was a process for measuring the quality of the care received in the home there was little evidence this had been implemented. People who lived in the home, district nurses and relatives had been surveyed in August 2007 with regard to care provision and laundry services and results had been analysed and an action plan developed. Although there had been some management monitoring of the home the deficiencies found in records and processes indicate that this was not effective. New polices and procedures had been provided in October 2007 but there was some evidence that these had not been implemented in areas such as medication management and management of peoples finances. Some of the service users finances were being managed by the home. Records of transaction were checked and balanced with the cash held. Receipts were provided for purchases but not for money taken in. Some of the transactions were not signed and none were witnessed. The policy and procedure was not being followed in relation to amounts of money held in the home and signing of transactions. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 26 There was little evidence that staff had received regular formal supervision recently with no evidence that the standard of six times a year would be achieved. Although there was some improvement, the management of health and safety had still not been fully maintained Mandatory training had been provided, including moving and handling and fire safety, since the last inspection and equipment such as hoists had been serviced. Records showed that weekly fire alarm and monthly emergency lighting tests had not been completed on a weekly basis in September and had not been completed in October until the 24 October 2007. There was no record of fire drills having been undertaken and although the manager stated that by the end of the inspection he had completed two fire drills there were no records to evidence the content of this or staff attendance. The home was not protected from the spread of fire, as at least one fire door did not all close fully on release and linen cupboard doors were not locked. There was poor risk assessment in the use of bed rails. The bed rails had not been fitted so that they were safe for people to use and left people at risk of entrapment. Bed rails had not been frequently reassessed to ensure they were safe to use. By the end of the inspection the manager had arranged for the district nurse to reassess the use of bedrails for people and had also completed in house risk assessments. The bedrails had been adjusted to reduce the risk of entrapment and a system to monitor the safety off the bedrails had been implemented. This should ensure that systems are safe in the future. Accident records were seen and detailed records of hospital visits or medical assistance had been maintained. An audit of individual falls was compiled and records of action taken, such as referral to the falls team, were maintained. Materials hazardous to health had been left so they were easily accessible to service users. Cleaning cupboards had been left unlocked and denturecleaning tablets had been left in bedrooms. General maintenance of the home had not been maintained. The main lounge carpet in Holly unit was frayed and torn causing a possible trip hazard and a fire extinguisher was not safely secured. The bath hoist seat in one of the bathrooms on Trent unit was chipped and could be hazard to people. This was taken out of commission until it could be replaced. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 2 X X X 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 1 2 1 Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 6 Requirement Timescale for action 01/01/08 2 OP7 15 3 OP8 13(4)(c) 4 OP9 13(2) The registered person must review the statement of purpose and service users guide and ensure the documents are up to date in respect of the management changes in the home. This is to ensure that people get accurate information about the home to assist them to make an informed choice. The registered person must 01/01/08 ensure that all service users care plans are reviewed and updated to ensure that the care required to meet needs is identified and recorded. The care plans must then be evaluated monthly to ensure they are kept up to date. The registered person must 01/01/08 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 timescale of 01/06/07 was not met.) The registered person must 29/10/07 ensure that medications are DS0000002887.V354692.R01.S.doc Version 5.2 Holly House Page 29 5 OP12 16(2)(m)( n) 6 OP16 17(2) 22(8) 7 OP19 23(4) 8 OP21 23(2) 9. OP25 23(2) 13(3) administered as prescribed, that records of administration are maintained and that medication is stored at the correct temperatures. This is to ensure service users have medication prescribed and the safe handling and storage of medications. (The timescale of 01/06/07 was not met) 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 timescale of 01/07/07 was not met.) The registered person must ensure that a record of all complaints and the action taken is maintained in the home. The registered person must supply to the Commission a statement containing a summary of the complaints received since the last inspection and the action taken. This to ensure that all complaints are appropriately managed. The registered person must ensure that fire doors close fully on release and linen cupboard doors are kept locked to minimise the risk and spread of fire in the home. (The timescale of 27/4/07 was not met) The registered person must ensure that toilet seats are repaired. This is to ensure comfort and safety. The registered person must ensure that there is hot water DS0000002887.V354692.R01.S.doc 01/01/08 01/01/08 29/10/07 01/01/08 01/01/08 Page 30 Holly House Version 5.2 10 OP26 16(k) 11 OP30 18(1) 12 OP31 9(2) 13 OP33 24 14 OP35 17 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 timescale of 01/06/07 was not met) The registered person must ensure that the home is kept free from offensive odours to ensure a comfortable environment for the service users. (The timescale of 01/07/07 was not met.) The registered person must further develop the training programme with regard to the specific needs of people living in the home. This is to ensure the changing needs of the people living in the home can be met. The registered person must provide evidence to the Commission that Mr Wade, current manager, has the required experience and all employment checks have been made in of this post including a Criminal Records Bureau enhanced check and references. This is to ensure that Mr Wade is adequately experienced for the manager’s role and to protect the service users. 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 timescale of 01/07/07 was not met.) The registered person must DS0000002887.V354692.R01.S.doc 01/01/08 01/02/08 01/01/08 01/02/08 01/10/08 Page 31 Holly House Version 5.2 15. OP36 18(2) 16 OP38 23(4) 17 OP38 23(4) 18 OP38 13(4) 19 OP38 13(4) ensure that where assistance is given with people’s finances all transactions are signed and witnessed and receipts are provided. This is to ensure that people’s finances are safeguarded. 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 timescale of 01/07/07 was not met.) The registered person must ensure that fire alarms are tested weekly to protect service users in the event of a fire and to minimise spread of fire in the home. (The timescale of 27/4/07 was not met) The registered person must provide evidence that all staff have received practical instruction in the action to take in the event of a fire in the home. This is to ensure the safety of people in the home in the event of a fire. The registered person must ensure that before bedrails are used bedrails fit the bed, risk assessments are in place with agreement to the use of the equipment. All bedrails fitted must be regularly reviewed to ensure continued appropriateness and safety. The registered person must ensure that materials hazardous to health are stored securely to protect service users. (The timescale of 27/4/07 was not met) DS0000002887.V354692.R01.S.doc 01/02/08 29/10/07 01/01/08 29/10/07 29/10/07 Holly House Version 5.2 Page 32 20 OP38 23(2) 13(4) The registered person must ensure that the environment is safe by repairing or replacing the carpet in the main lounge in Holly unit, securing the fire extinguisher and replacing the chipped bath hoist seat. 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP7 OP26 OP19 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. The registered person should ensure that blinds are replaced or repaired. To improve the visual aspect of the home for the people who live there. Holly House DS0000002887.V354692.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 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. 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