Inspection on 09/05/08 for Holly House

This inspection was carried out on 9th May 2008.

CSCI found this care home to be providing an Adequate service.

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 29/10/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Holly House 124 High Street Burringham Scunthorpe North Lincolnshire DN17 3LY Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 9th and 13th May 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holly House DS0000002887.V364292.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.V364292.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 Manager post 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.V364292.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 29th October 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 a more 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 £357.34 - £406.34. Additional charges included Chiropody, Hairdresser, Escort duty and Newspapers. Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes This inspection was unannounced and took place over two days in May 2008. 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. We spoke to people who lived in the home and were able to answer some questions about the home. 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. We also spoke to the manager; area manager and the manager from another home that was supporting the manager. Records kept in the home were 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. A random inspection had been conducted in March 2008 to check compliance with requirements set at the previous key inspection. Findings from the random inspection are also included in this inspection. A number of requirements had been met at the random inspection. What the service does well: They provided people with information to help them make an informed choice about the home. The home provided a wide variety of communal space and different places to sit. The atmosphere was warm and friendly and the environment homely. The home was clean tidy and well maintained. The gardens were attractive and secure and accessible to the people who lived in the home so the gardens could be enjoyed safely. Garden furniture and raised flowerbeds had also been provided. Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 6 The people who lived in the home said that the staff were good. They felt they were treated with respect and their privacy was upheld People were able to look after their own medications and were well supported in this task by the staff. People generally enjoyed living at the home and the meals provided. They were enabled to maintain contact with relatives and friends as they wished. Procedures were in place to ensure that complaints were taken seriously and acted upon. There were systems in place to ensure that people were protected from abuse. They made sure that staff respect people’s privacy and dignity at all times particularly when entering bedrooms and assisting with personal care. They made sure that people had adequate choice in the meals provided. They had provided mandatory training such as training in moving and handling, medication and safeguarding adults and refresher training had been provided since the last inspection. What has improved since the last inspection? What they could do better: They must make sure that people have all the information about the service they are to receive by completing contracts/terms and conditions and providing these to people. They must make sure that all care plans set out how peoples assessed needs are to be met. They must ensure that these are kept up to date. They must ensure people’s health is monitored, care is provided as planned and monitoring records are completed. They must make sure that when they are Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 7 concerned about people’s health they record the actions taken in response to this. They must make sure that people are fully protected by obtaining all the two written references prior to employment of staff and safeguarding training in induction. They must keep an accurate record of the staff on duty in the home. They must make sure that bedrails are regularly checked to ensure that they are safely fitted. 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.V364292.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.V364292.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 People were provided with detailed information about the home to assist them to make an informed choice about the service although contracts/statements of terms and conditions were not always fully completed. People had had their needs assessed 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. They had reviewed the statement of purpose and service users guide to make sure the documents were up to date in respect of the management changes in the home. Holly House DS0000002887.V364292.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. However the fee payable had not been completed on one contract and another did not have the individual details completed such as fee and room to be occupied and neither the person living in the home nor their representative had signed it. There was evidence in the care files examined that all the service users had had 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. In the assessment most recently completed by the home the details were basic. The assessments could be improved by recording more detail about peoples daily routines, social needs and interests and likes and dislikes. Social services assessments and care plans had been obtained. Holly House DS0000002887.V364292.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 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. There was evidence that through regular detailed management audit the systems and records in the home were improving. However there were still some consistency issues in record keeping to evidence action taken where there were concerns about people’s health. People were enabled to self medicate if they wished. Medication processes and record keeping had improved to a satisfactory level through regular management audits. People who lived in the home felt they were treated with respect and their privacy was upheld. Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 12 EVIDENCE: The care plans were examined at both the random inspection and this inspection. At the random inspection in March 2008 there was some evidence that care plans had been updated and evaluated monthly and reviews had been completed. However the care plans did not always identify all people’s needs or specify the care required to meet needs. This was particularly evident where people required support and assistance with eating and drinking or had had weight loss. Evaluations lacked detail and were not cross referenced to monitoring records such as weight records. Records to monitor people’s intake had not been consistently recorded to be an effective tool with which to identify problems with eating and drinking. Where a person had had frequent falls recorded and had been referred to the falls team, the evaluations did not identify the number of accidents recorded in any one month and did not make a judgement as to the effectiveness of the measures taken to reduce the risk of falls. There were some improvements at this inspection and the manager provided evidence that he had completed a detailed audit of all the care files and given instruction to staff as to the improvements required. Staff had completed this work to care plans to varying levels. Where all the instructions had been followed care plans were detailed and up to date. The manager had planned supervision with staff to ensure compliance with his instructions. There were improvements in the care relating to health monitoring although records did not always reflect the care required or provided. For example where one person was observed receiving regular pressure area care there was no support plan for this but daily charts detailing the care provided were maintained. Daily diary records did not always detail the action taken where it was recorded that staff were concerned about a person’s health. In one case the dairy records stated that a person had been admitted to accident and emergency following a fall but on discharge pain continued. A senior member of staff stated that the GP had been contacted and was due to visit on the day of the inspection but there was no recorded evidence of this. The manager was requested to investigate the action taken in response to pain continuing and provide a written report of his findings to the Commission. Details regarding people’s dietary needs were recorded on assessment and the information was provided to the cooks. The care plans showed that people had been weighed monthly. Appropriate scales were available for people 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. Records of one person’s dietary intake were still not consistently maintained to provide an effective tool to identify problems in this area. Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 13 At the random inspection the medication storage had been moved to ensure that temperatures of the storage facilities could be maintained at an appropriate level. Records of temperatures were maintained although these were not consistently completed on a daily basis. Hand transcribed medication records were not consistently completed in that some had been witnessed and signed and others had not. The manager was reminded that it is important to double check hand transcribed records to minimise the risk of error. In one case three were two instances where medication had not been signed as administered or a code entered as to why the medication had not been taken. Periodic medication audits as part of the quality monitoring process had been implemented and staff had received additional training since the last inspection. At this inspection the manager could evidence that through regular management audits medication records had improved in terms of clarity and accuracy. Hand transcribed records had been double checked for accuracy and there were no gaps in the administration records examined. 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 person was self-medicating eye drops. There was evidence that staff monitored and supported the person who was self medicating. There was evidence from observation and people’s comments that staff respected people’s privacy when entering bedrooms by knocking on doors before entering. People said 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 people confirmed that there was good communication with people who lived in the home. There was a lively and homely feel in the home; all the people spoken with who lived in the home said the staff were very good. Holly House DS0000002887.V364292.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 good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People enjoyed living at the home and the meals and activities provided. People were enabled to maintain contact with relatives and friends as they wished. EVIDENCE: At the random inspection in March 2008 there had been some efforts to improve the activities in the home and people were engaged in activities during the inspection. An experienced activities coordinator had been employed for fifteen hours per week and records of activities were maintained although these had not been completed on a consistent basis. There was evidence that people had been consulted about the activities in the home and a regular communication group and fund raising events were planned. At this inspection there was evidence that activities and associated records had continued to improve. Records showed that activities were individualised and varied. More detailed individual assessment and development of social care Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 15 plans will make sure that this area continues to develop to meet peoples needs. 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 peoples likes and dislikes. 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. 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, comments included ‘the food is good”, and “choices are offered”. New menus had been developed in consultation with people who lived in the home and showed there were at least two choices at breakfast, lunch and tea. Individuals confirmed that they 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. 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. Changes to the way the staff routines were organised made sure that more staff were available to assist people in taking their meals and they were observed to offer assistance in a more appropriate manner. Holly House DS0000002887.V364292.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 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 systems in place to protect people from abuse although recruitment procedures and staff training had not been fully implemented in all cases. EVIDENCE: Not all records of complaints were available at the previous key inspection. They were requested to provide a summary of the complaints and the action taken to the Commission, this was received within the time scales. At the random inspection they had maintained a record of all complaints and the action taken. At this inspection records of complaints and actions taken were available although the management had not been following its own procedures in terms of recording details on a complaints form on receipt of a complaint. The complaints procedure was displayed in the home and was also contained in information about the home. Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 17 The home also had detailed policies and procedures to support practice to protect people from abuse and these were made available to staff in the handbook provided on employment. At the previous key inspection there was evidence that safeguarding adults training was provided and the training provider confirmed that they visited the home on three occasions in August 2007 and provided training to the staff in safeguarding adults. At this inspection training records showed that four of the most recently employed staff had not received training in this area and the manager was advised that this is completed as part of the induction process. A safeguarding adults investigation by the Police was ongoing following a referral by the manager to the Local Authority with regards to unexplained bruising to a person living in the home. Prior to writing this report a further incident was also reported by the manager regarding an allegation of theft and the police investigation is ongoing. The manager has taken these incidents seriously and referred them to the appropriate authorities. The recruitment process had not always been fully implemented and all checks completed to make sure that staff were suitable to work with vulnerable people. In two cases as only one written reference rather than two had been received prior to employment. Holly House DS0000002887.V364292.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 and 26. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offered spacious homely accommodation. There was a significant improvement in the maintenance and cleanliness of the home. The management had been proactive in addressing requirements from the previous inspection. EVIDENCE: 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. At the random inspection in March 2008 there was evidence that the management had addressed many of the requirements from the previous key inspection. Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 19 They had consulted with the fire officer and completed a schedule of works to make sure that fire doors closed fully on release and linen cupboard doors were locked. This was required to minimise the risk and spread of fire in the home. They had consulted with plumbers and work was ongoing to ensure that there was hot water close to but not exceeding 43°C in service users ensuites. This was required to promote service users comfort and minimise the risk of spread of infection. They had made sure that the home was free from offensive odours to ensure a comfortable environment for the service users. They had replaced broken toilet seats to ensure comfort and safety. They had provided a sluice room to clean commode pots rather than use bathrooms. They had made sure that broken blinds were replaced or repaired to improve the visual aspect of the home for the people who live there. At this inspection there was ongoing programme of redecoration and refurbishment in communal areas in the Trent unit and new chairs had been purchased. A large conservatory had been built to further expand the communal space. The tiled area in the hallway on Trent had been also been carpeted. The issues relating to the hot water in the ensuites in Holly unit had been addressed. Holly House DS0000002887.V364292.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 adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Minimum staffing numbers had not been accurately calculated and risks relating to the design of the building had not been fully identified when planning staffing levels, which may put people at risk. This issue was addressed by the end of the inspection. Not all the recruitment checks had been completed in two cases to make sure that people were suitable to work in the home. Staff had received training and supervision their role. EVIDENCE: The staff rota showed that staffing had been reduced from 6 staff to 5 on some day shifts from the last inspection and the staff confirmed this to be the case. The management stated this was due to reduced occupancy and that rotas had been planned using residential forum guidelines and the area manager provided evidence of this. However not all the elements of the guidance tool had been correctly used and staffing requirements were therefore underestimated. The homes design means that the staff have to work in two groups. By only providing two staff on one side where there were a number of people who required two carers to assist them with personal care this meant that the other people would be left unsupervised and therefore at risk. This was evident Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 21 during the tour of the building where one person with poor mobility was found trying to stand to go to the toilet and there were no staff available to assist them. The manager was advised that the minimum care staff requirements for the home must be six on day shifts to make sure that people are adequately supervised and assisted. An immediate requirement notice was served to this effect and was met on the second day of the inspection. Rotas evidenced and staff stated that staff from the providers other homes or agency staff 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. However rotas had not always been accurately completed to show who was in the home, this had to be confirmed from the signing book and agency timesheets. 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. The people spoken with in the inspection all said the staff were “very good”. The pre inspection information provided by the home stated that 15 of the 21 care staff had achieved at least NVQ 2 and four were training for this qualification. Some of the staff spoken with had achieved NVQ Qualifications. Examination of files for three staff that had most recently commenced employment showed that recruitment checks had been completed although in two cases only one written reference instead of two had been obtained prior to employment. All checks must be obtained prior to employment to make sure that the person is suitable for the post. There was evidence that mandatory training had been provided. 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 provided. Staff confirmed that there had been training in a variety of subjects. At the random inspection they had further developed the training programme with regard to the specific needs of people living in the home. This included dementia training and weekly in-house training sessions in different subjects relating to the needs of those living in the home. There was evidence that induction training had been provided using common induction standards. Workbooks were provided for new starters although these were not available in cases in the home as they are given to staff. 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. One new member of staff stated that they had Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 22 completed induction training and shifts shadowing other staff. They stated that they felt they felt supported and that the home was very welcoming. The manager was advised to ensure safeguarding adults training was provided within induction to ensure that all staff received this guidance as soon as possible on starting work at the home. (See standard 18) Staff and records confirmed that the manager provided formal supervision for the staff. Holly House DS0000002887.V364292.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, 33, 35, 36 and 38. 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 have been four managers in the home in 2007 and the home had not had a registered manager since April 2007. However there has been improvement in all areas of the home since the last key inspection and this has been as a result of more effective management, quality monitoring and support by the providers. EVIDENCE: The 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. He stated he had completed other mandatory training but recognised that he would Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 24 require further training for this role in areas such as supervision and health and safety. The manager was being supported in his role by another manager form a sister home and the area manager. At the random inspection in March the registered, Mr Wades employment file. Employment checks had not been made in respect of him being employed as acting manager which must include a Criminal Records Bureau (CRB) enhanced check and references although these checks had been completed for his previous role within the company. The registered person was advised that checks must be repeated in respect of the acting managers role. This is to ensure that Mr Wade is suitable for this role and to protect the people living in the home. At his inspection Mr Wade stated that a CRB check had been applied for. He states that he had commenced the Registered Managers Award but had not applied as yet to the commission to be the Registered Manager the home. At the random inspection there was evidence that they had implemented 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 people living in the home. This included audits of the systems in the home and surveys. Action plans had been developed from the information gathered and there was evidence that feedback had been given at meetings. At this inspection there was evidence that this work had continued and there was improvement in all areas of the home. The manager had completed audits of the care plans since the random inspection and improvements could be seen where the action plans had been implemented. There was also evidence that people who lived in the home had been consulted about the meals they received and the menus had been reviewed in light of the comments made. At the random inspection standard thirty-five was unable to be assessed, as the manager couldn’t open the safe where he stated the records were held. At his inspection a new safe had been purchased. The records balanced with cash held on behalf of the people who lived in the home and there was evidence of regular management audits of the records. At the random inspection there was evidence that a programme of staff supervision had commenced and records of the content of supervision were maintained. This had been continued at this inspection and a plan for the year had been developed. At the random inspection requirements arising from the previous key inspection relating to health and safety were checked for compliance. The majority of these had been met. Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 25 The records showed that fire alarms had been tested weekly. This was required to protect people in the event of a fire and to minimise spread of fire in the home. They had made sure that materials hazardous to health were stored securely to protect people. The records showed that all staff had been provided with practical instruction in the action to take in the event of a fire in the home. The carpet in the main lounge in Holly unit had been replaced, the fire extinguisher had been secured and they had replaced the chipped bath hoist seat. They had not made sure in one case that a risk assessment had been fully completed and agreement to the use of the equipment sought before bedrails were used. This is essential to ensure the safe and appropriate use of bedrails. At this inspection risk assessments were in place but safety checks of bedrails had not been completed consistently and on examination one bedrail required adjustment to prevent excessive movement of the rail. The manager had obtained a copy of the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on bedrails and was advised to use this to develop a robust system to ensure safety when using bed rails. Accidents in the home were recorded and basic auditing was completed. The manager was strongly advised at the random inspection to audit accidents in more detail as the incidence had increased over the three months prior to the inspection. At this inspection the manager evidenced that he had increased auditing the accidents in the home and records showed the actions taken. The accidents in the home had reduced since the random inspection. Although the manager stated this had been done he could not provide evidence that fire alarms and fire fighting equipment had been tested as due in March 2008. He was requested to provide evidence to the Commission. Holly House DS0000002887.V364292.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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Holly House DS0000002887.V364292.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(c) Requirement Timescale for action 01/09/08 2 OP7 15 3 OP8 13(4)(c) 4 OP8 37(e) The registered person must ensure that contracts provided to people living in the home are fully completed to ensure that people have the all information about the service to be provided. The registered person must 01/08/08 ensure that care plans identify all peoples care needs identified at assessment and are updated as needs change. This is to ensure that staff has all the necessary information to make sure peoples care needs are met. The registered person must 01/08/08 ensure that health is monitored and when people’s health needs change or there are concerns, records of the actions taken are maintained. This is to make sure that intervention is appropriate and timely and to minimise the risk of unnecessary deterioration of people’s health. The registered person must 14/07/08 provide a copy of his investigation as to the action taken where the dairy records stated that a person had been DS0000002887.V364292.R01.S.doc Version 5.2 Holly House Page 28 5 OP18 13(6) 6 OP27 17(2) 7 OP29 19 8 OP31 9(2) 9 OP38 13(4) admitted to accident and emergency following a fall but on discharge pain continued. This is to ensure that appropriate and timely action has been taken. The registered person must ensure that safeguarding adults training is provided as part of induction. This to make sure that all staff can recognise the signs/symptoms of abuse and are made aware of the procedures for referral of suspicions of abuse. The registered person must make sure that there is an accurate record of all staff on duty in the home and that this includes their full name and identifies their role. The registered person must make that two written references are obtained prior to staff starting employment in the home. This is to make sure that staff employed are suitable to work with vulnerable people. The registered person must provide evidence to the Commission that Mr Wade, current manager, that all employment checks have been made in respect 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 people living in the home. (The timescale of 01/01/08 and 01/06/08 was not met). The registered person must ensure that all bedrails fitted are regularly reviewed to ensure continued appropriateness and safety. (The timescale of 29/10/07 and DS0000002887.V364292.R01.S.doc 09/05/08 09/05/08 09/05/08 14/07/08 09/05/08 Holly House Version 5.2 Page 29 18/03/08 was not met). 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 Refer to Standard OP3 Good Practice Recommendations The registered person should further develop the assessment process to provide more detailed information of peoples daily routines, social needs and interests and likes and dislikes. The registered person should make sure that Mr Wade applies to the Commission to be the Registered Manager. 2 OP31 Holly House DS0000002887.V364292.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V364292.R01.S.doc Version 5.2 Page 31 - 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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