CARE HOMES FOR OLDER PEOPLE
Holly House (Milton Malsor) 36 Green Street Milton Malsor Northants NN7 3AT Lead Inspector
Stephanie Vaughan Unannounced Inspection 7th November 2005 13:30 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 (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Holly House (Milton Malsor) Address 36 Green Street Milton Malsor Northants NN7 3AT 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) 01604 859 188 01923 840278 Mr Parvin Kumar Menon Mrs Madhu Menon Vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 06/06/05 Brief Description of the Service: Holly House is a residential care home situated in the village of Milton Malsor, south east of Northampton. The home provides care for 22 older people. The category of care provided is for residents with old age that do not fall into any other category. The premises consist of a detached house, all rooms are single with en-suite facility. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced statutory inspection took place over a period of four and a quarter hours following a period of two hours preparation, which included a review of previous inspection reports, monitoring visits, reviewing outstanding requirements, service history, correspondence and other documentation. The methodology for the inspection included case tracking, where a sample of residents were selected and all aspects of their care and documentation were reviewed. In addition to discussion with residents, staff and management, a limited tour of the building was conducted. A review of requirements and recommendation was also made following the previous inspection and subsequent monitoring visit conducted on the eighth of August 2005. Five requirements from the inspection dated the sixth June 2005 were reviewed, four of these have now been met and one remains outstanding. Eight requirements from the monitoring visit dated the eighth August 2005 were reviewed, five of these have now been met, two have been partially met and one continues to remain outstanding. At the time of the last inspection one complaint remained outstanding and pertained to the staff being employed at the home without appropriate Criminal Records Bureau Clearances or movement and handling training. On conclusion of this investigation the complaint was found to be upheld. No further complaints have been received What the service does well:
The home has good admission procedures, which ensure that residents needs are met and residents satisfaction with the services provided. Individual plans of care contain detailed instruction to staff to enable them to meet the needs of residents Individual plans of care evidence that residents’ health care needs are met and include risk assessments for falls, pressure, nutrition and movement and handling.
Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 6 Where risks are identified appropriate action is taken to reduce and manage the risk. Guidance is sought from appropriate health care specialists as required. Residents confirmed satisfaction with their private and communal accommodation and the home was clean and hygienic throughout the areas viewed. Residents are able to hold small amount of cash, as the home does not manage residents’ money. However the home does offer a billing system whereby residents are able to access facilities such as hairdressing and podiatry. What has improved since the last inspection? What they could do better: Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 7 The Statement of Purpose continues to contain some factual inaccuracies pertaining to the organisational structure and staff training. This must be further addressed and kept under review to ensure that the statement of purpose continues to be relevant to the current service. The revised Statement of Purpose must also be made available to residents and their representatives. Further improvements in the care planning process are required to ensure that residents and their representatives are involved. Individual plans of care should identify the designated key worker and evidence that they participate along with the resident in the review. A requirement was made that residents must have suitable privacy locks fitted to their bedroom doors, subject to their choice and risk assessment, by the 31st July 2005. The Acting Manager confirmed that residents are now consulted regarding their wishes and that a proposal to fit appropriate locks is included within the service development plan. A copy of which must be submitted to the Commission for Social Care Inspection Improvements to the provision of activities programme and the management of the lunchtime menu should be made to ensure that residents have choice and are informed. The complaints policy still fails to provide the potential complainant of the right to complain to the Commission for Social Care Inspection at any stage of the complaint including the first instance. Management continue to practice unsafe recruitment practices and fail in their duty to protect vulnerable adults. It is of concern that the home has been without a Registered Manager since the current owners acquired the facility. However the Acting Manager has now completed the National Vocational Qualification level 4 and confirms that an application is to be submitted to the Commission for Social Care Inspection in the near future. However continued non-compliance with the Care Home Regulations 2001 has implications for the registration process and the fitness of the applicant to become the Registered Manager. No progress has been made regarding the recommended review of the homes policies regarding range, content and current relevance 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
Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 8 contacting your local CSCI office. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 9 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 (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 The Statement of Purpose does not provide residents and their representatives with current, accurate information. However the admission process is robust. EVIDENCE: Following a requirement made at the last inspection and subsequent monitoring visit a revised version of the Statement of Purpose has been submitted to the Commission for Social Care Inspection. However this document continues to contain some factual inaccuracies pertaining to the organisational structure and staff training. This must be further addressed and kept under review to ensure that the statement of purpose continues to be relevant to the current service. The revised statement of purpose must also be made available to residents and their representatives. The home has had one recent admission and the resident confirmed that she had had an opportunity to visit the home, meet fellow residents and the staff and to view the facilities prior to admission. This resident was able to conform
Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 11 satisfaction with the admission process, the facilities available within the home and that the home was able to meet her needs. The individual plan of care evidenced a thorough pre admission assessment that specified all of the residents needs and provided information about how these needs were to be addressed. In addition, detailed individual plans of care were being developed, based on the initial assessment and within an appropriate time frame. Standard six is not applicable, as the home does not offer Intermediate Care. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 9 & 10 Individual plans of care contain detailed instruction to staff to enable them to meet the needs of residents. However, further improvements are required to ensure that residents and their representatives are involved. EVIDENCE: Individual plans of care are developed following the preadmission assessment and are subsequently reviewed on a monthly basis. However this is currently undertaken solely by the acting manager. There continues to be no evidence that residents or their representatives are involved in the care planning process or review and this must be addressed. The acting manager confirmed that senior care staff have recently had training in care planning and that the key worker system was to be formalised. Individual plans of care should identify the designated key worker and evidence that they participate along with the resident in the review. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 13 Individual plans of care evidence that residents’ health care needs are met and include risk assessments for falls, pressure, nutrition and movement and handling. Where risks are identified appropriate action is taken to reduce and manage the risk. Guidance is sought from appropriate health care specialists as required. The home has had a recent inspection by a Registered Pharmacist and this was reported to be satisfactory. The Acting Manager is required to submit a copy of the report to the Commission for Social Care Inspection by the 17th November 2005, following requirements made in previous inspection reports. A requirement was made that residents must have suitable privacy locks fitted to their bedroom doors, subject to their choice and risk assessment, by the 31st July 2005. However the Service Users Guide has been amended to inform residents of their right to have the appropriate locks fitted to their bedroom door and to hold the keys should they wish to do so. Discussion with the acting manager confirmed that residents were to be consulted about this and that the service development plan contained a proposal to fit the appropriate locks. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Improvements to the provision of activities programme and the management of the lunchtime menu should be made to ensure that residents are able to make informed choices. EVIDENCE: The activities programme was displayed on the notice board within the dining room, however this was dated 2003. The acting manager conformed that this was still accurate. However, a recent residents satisfaction survey has been conducted by the home and activities were one of the subjects that were addressed. The results confirmed that approximately 30 of residents were happy with the existing arrangements and a further 30 of residents preferred not to have any activities. However a further 30 indicated that they would like to have a wider variety of activities provided. The acting manager confirmed that this was currently being reviewed to enable residents to express specific preferences with a view to providing individualised activities. The inspector viewed the teatime service and noted that residents had a wide variety of choice based on their specific preferences, immediately prior to the meal. Food appeared to be well presented and of adequate proportion. Meals are served within the dining room, the sitting room or the residents’ private accommodation as required.
Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 15 Residents spoken to confirmed satisfaction with the food provided. Appropriate records are maintained regarding the choice of the meal provided. However the home has a set of standard lunchtime seasonal rolling menus within the kitchen, which do not correspond with the records of the food provided. This was discussed with the management who confirmed that residents were consulted on a regular basis and that their preferences were so well known to staff that the standard menus were not adhered to. It was therefore agreed that the management would formalise this arrangement by documented weekly menu planning sessions with residents and that the daily choices should be displayed on a board within the dining room. Accurate records of the food chosen must be maintained in order to enable the management to ensure that an individual was in receipt of a balanced diet and that the source of any potential food poisoning be identified. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The complaints policy fails to provide the potential complainant of the right to complain to the Commission for Social Care Inspection at any stage of the complaint including the first instance. EVIDENCE: Following requirements made at the previous inspection the Commission for Social Care Inspection have now received a revised complaint policy. However the policy still fails to provide the potential complainant of the right to complain to the Commission for Social Care Inspection at any stage of the complaint including the first instance. The complaints policy must be further revised and made available to residents and their representatives. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 & 26 The standard of the environment is suitable for the needs of residents. EVIDENCE: A limited tour of the premises was conducted and seen to comply with the required standards. Disabled access to the main entrance has been improved by the provision of a permanent ramp and handrail. Residents confirmed satisfaction with their private and communal accommodation. The home appeared to be clean and hygienic throughout the areas viewed. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 Management continue to practice unsafe recruitment practices and fail in their duty to protect vulnerable adults. EVIDENCE: The staff file of the most recently employed staff member was viewed, which failed to contain the required information. In fact the member of staff was originally employed by the home in 2004 on the basis of a pre-existing Criminal Records Bureau Clearance, which cited the previous employer There was no evidence that the home had applied for a Criminal Records Bureau Clearance in their own right or an associated povafirst check nor any evidence that references had been obtained. The staff member had left employment due to personal reasons, however has now recommenced employment at the home although there was no start date recorded. The Acting Manager confirmed that she had started three weeks ago, however the povafirst check had only been applied for ten days ago, and that the clearance has not yet been received. The acting manager produced evidence that a new Criminal Records Bureau Clearance was to be applied for in the form of a completed application form.
Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 19 However this had not been submitted, as it was understood that the staff member might be returning to her own country in the near future. In addition the management had again failed to obtain appropriate references or explore any periods of time that were unaccounted for, on the basis that the staff member was already known to them It is of serious concern to the Commission for Social Care Inspection that despite several requirements made during the last twelve months as a result of inspections, monitoring visits and complaint investigations that the management continue to practice unsafe recruitment practices and their duty in the Protection Of Vulnerable Adults. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33, 35 & 38 Appropriate policies and procedures are not in place to protect residents and ensure safe working practices. EVIDENCE: It is of concern that the home has been without a Registered Manager since the current owners acquired the facility. However the Acting Manager has now completed the National Vocational Qualification level 4 and is planning to submit an application to the Commission for Social Care Inspection in the near future. In addition the management and senior staff have recently undertaken training in dementia care to enable them to meet the needs of existing and potential residents However continued non-compliance with the Care Home Regulations 2001 has implications for the registration process and the fitness of the applicant to become the Registered Manager.
Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 21 The home have recently implemented and conducted a residents survey, which covers a range of issues and identifies areas of satisfaction and areas that could be improved to ensure residents satisfaction and service development. Residents are able to hold small amount of cash, as the home does not manage residents’ money. However the home does offer a billing system whereby residents are able to access facilities such as hairdressing and podiatry. The home has had a recent inspection by the Environmental Health Officer and a report submitted to the Commission for Social Care Inspection as required at the last inspection. Outstanding issues have now been addressed and the hot water supply has been restored to the staff lavatory along with the provision of appropriate facilities. The Acting Manager confirmed that no progress has been made regarding the recommended review of the homes policies regarding range, content and current relevance. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 22 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x 3 x x x 3 x x 3 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 3 x 3 x x 1 Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 23 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 4 (1&2) Requirement The Statement of Purpose must be further amended, regularly reviewed and made available for Residents and their Representatives. The care plans must evidence the involvement of residents or their representatives in their development and review. Outstanding Requirement from 31st July 2005 The registered person must submit a copy if the pharmacist’s report to the Commission. Outstanding Requirement from the 8th March 2005. The service development plan must be submitted to the Commission for Social Care Inspection A copy of the revised activities programme must be submitted to the Commission for Social Care Inspection Management to the lunchtime menu must be improved to evidence that residents are able to participate in the menu planning.
DS0000043334.V256328.R01.S.doc Timescale for action 01/12/05 2 OP7 15 (1) 01/12/05 3 OP9 13 (2) 17/11/05 4 OP10 12 (1,a) 17/11/05 5 OP12 12 (m&n) 01/01/06 6 OP12 12(1,2,3, 4) 17/11/05 Holly House (Milton Malsor) Version 5.0 Page 24 7 OP12 16(I) Schedule 4.13 8 OP16 22 9 OP29 19 Accurate records of the food 17/11/05 chosen must be maintained in order to enable the management to ensure that an individual was in receipt of a balanced diet and that the source of any potential food poisoning be identified The complaints policy must be 17/11/05 further revised to include the required information and made available to residents and their representatives New or previously employed staff 07/11/05 must not commence employment within the home without first obtaining satisfactory references, including one from the previous employer and exploration of any absences and periods of non employment Immediate requirement 10 OP29 19 New or previously employed staff 07/11/05 must not commence employment within the home without first obtaining receipt of a satisfactory Criminal Records Bureau Clearance and povafirst check. Immediate requirement Criminal Records Bureau Clearance must be specific for the home in which the employee is employed Immediate requirement The acting manager must seek registration by the Commission for Social Care Inspection The homes polices and procedures must be reviewed to ensure that staff have access to a full range of appropriate policies 07/11/05 11 OP29 19 12 13 OP31 OP33 7&8 10 (1) 12(1) 01/12/06 01/01/06 Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 25 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 OP7 Good Practice Recommendations Individual plans of care should identify the designated key worker and evidence that they participate along with the resident in the review. Holly House (Milton Malsor) DS0000043334.V256328.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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