Inspection on 03/04/07 for Holly Lodge

This inspection was carried out on 3rd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holly Lodge 13/11/06

Holly Lodge 02/03/06

Holly Lodge 05/09/05

Holly Lodge 03/03/05

Holly Lodge 08/09/04

Holly Lodge 04/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Holly Lodge 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA Lead Inspector Mrs Jean Edwards Unannounced Inspection 3rd & 5th April 2007 08:30 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 Lodge DS0000024971.V333038.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 Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Lodge Address 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA 01384 373306 01384 378160 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mohammed Iftikhar Ali Mrs Paula Hubble Care Home 21 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (2), Old age, not of places falling within any other category (19) Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 2 DE, 2 MD and up to 19 OP Date of last inspection 13/11/06 Brief Description of the Service: Holly Lodge is a residential home registered to provide 24-hour care for 21 people over the age of 65. It is located on a residential road just off the main Hagley Road in Oldswinford near to the church. It is accessible by public transport and close to local shops and public houses. The home has 19 single rooms and 1 double room, 2 lounges and a conservatory. There is a well-maintained garden to the front and rear and parking facilities at the side. Accommodation is provided over 3 floors accessible via passenger lifts or staircase. The level of fees for this home is currently between £398.00 and £430.00 per week, including a range of individual third party top up fees from £43 - £75 per week. Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the key inspection visit for 2007 - 8, undertaken by an inspector from the Commission for Social Care Inspection (CSCI), for nine hours over two weekdays. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with registered manager and staff on duty during the visits, discussions with residents and examination of a number of records. Other information was gathered before this inspection visit from notification of incidents, accidents and events. Twenty service user surveys were sent to the home by the CSCI and an analysis of the nine survey forms returned is contained throughout this report. Two relatives survey forms have also been returned and collated. Results are generally positive. There are currently 20 residents living at the home. During the visit the inspector spoke to the majority of residents. Longer discussions have taken place with the residents whose care was looked at in depth. The inspection has included a tour of the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with permission. What the service does well: Relatives and residents continue to express high levels of satisfaction with the service provided. There is easy to read information available about the home, which helps people to make decisions about where to live. In answer to the questions on the CSCI service user survey forms all 9 responses indicate that people have received satisfactory information to help them make decisions and have received a contract with terms and conditions of residency from the home. Holly Lodge continues to provide a high level of good quality care within a homely environment. All staff are cheerful and committed to meeting each residents needs and make sure that they are treated with dignity and respect. The home continues to excel in the number and variety of activities it provides. There is good evidence that residents medical and healthcare needs are met. Visitors are warmly welcomed to the home and are offered refreshments, support and appropriate information with relatives feeling there is good communication between them and the home. There is a proactive approach towards any concerns or complaints, and efforts are made to listen and improve the service. The CSCI relatives survey comments about what the home does well are, they understand the feelings and are very kind , Holly Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 6 Lodge gives a warm, caring environment for those who can no longer look after themselves, and Holly Lodge cares well for their residents and a resident comments, very well served in all respects. Holly Lodge is warm, clean and homely. All responses from the CSCI service user and relatives survey indicate that the home is always clean and fresh. The registered manager has taken advantage of a Government grant to apply for money to develop a sensory garden with raised beds in the enclosed front garden at the home. There are a number of residents who enjoy gardening and will have great pleasure from the hands on experience. This inspection has been conducted with full co-operation of the registered manager, staff and residents. The atmosphere through out the inspection has been relaxed and friendly. The Inspector would like to thank the registered manager, staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? The development of new care plans and fuller health care screening and assessments have been put in place to make sure that residents needs are properly met and they are well cared for. Small frequent nutritious meals are offered to residents with poor appetite, weight loss or nutritionally at risk, though records of meals and snacks consumed must contain more detail. The homes system for the management and administration of residents medication has been improvement in a number of areas, though there are still some further improvements needed, so that it is a safe as possible. The registered manager has obtained a copy of Dudley MBC multi-agency procedure for the protection of vulnerable adults Safeguard & Protect and is in the process of making sure all staff know how to safeguard vulnerable residents. A new radio - pager nurse call has been installed to replace the old very noisy system, which has improved the environment, making it calmer and more peaceful. The residents and staff agree the new system is more effective in summoning staff, when assistance is needed. Five year fixed wiring check has taken place and extensive work is in progress to rewire the home. New radiator covers have been purchased and are being fitted so that all radiators are covered and provide good protection for residents from potential injury. All exposed pipe work is also now guarded for extra protection. There are plans to replace all worn carpets when the rewiring work and redecoration is complete. The plans also include new, more appropriate floor covering for bathrooms, to improve the control of any potential infection. The registered manager has provided hand washing signs in Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 7 all communal bathing, toilet facilities and laundry facilities and has displayed copies of the homes laundry policy and infection control procedures in the laundry area. The registered persons have plans to extend the home to improve the environment, with a larger laundry and office space. The registered manager has recruited three additional care assistants and now has more to time to devote to develop the services provided by the home and monitor care delivered to residents to make sure all aspects of the home meet and exceed the Care Homes National Minimum Standards for Older People. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holly Lodge DS0000024971.V333038.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 Lodge DS0000024971.V333038.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): 2, 3, 4, 5 Quality in this outcome area is good. The residents have a contract / terms and conditions of occupancy, the document this has the effect that residents and their advocates have clear information regarding their rights and entitlements, any agreed restrictions and how care will be provided. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. The home actively encourages introductory visits and there is evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has obtained copies of the Office of Fair Trading publication and has taken account of the revised Care homes Regulations and Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 10 has incorporated changes into the homes contracts and terms and conditions of residency. There is evidence from the service user surveys and sample of residents case files that all residents have a comprehensive, clear contract, with fees and rights and responsibilities documented. There are also clear details of fees and third party top up arrangements included in contracts / terms and conditions, which is very positive. From discussions and observations there is evidence that all prospective residents and families have an invitation to visit before coming to live at the home. There was an exception in the most recent admission because the person was resident in another home. On this occasion the registered manager visited the person at the home, where she had been admitted for a respite short stay, so she could assess the prospective needs, before agreeing the admission to Holly Lodge. The residents plan at Holly Lodge includes a longer term goal for her to be rehabilitated for a possible return to her own home. The sample of residents case files demonstrates that the registered manager writes to each resident and their family to confirm that the home can meet their needs. There are currently 20 residents accommodated at the home, and discussions with the registered manager and assessment of the pre inspection information supplied by the home indicates that there is an awareness that if and when residents deteriorate they may need care, which the home is not able and not registered to provide. The most recent situation has been handled with sensitivity and the registered manager and staff have provided assistance and support to the resident and family for a more appropriate alternative placement to be found. The staff show that they are aware of residents needs, and there are improved records of each residents preferences such as rising, retiring, likes and dislikes, preferred gender of staff to give assistance with personal care, which reduces risks of reliance on verbal communication between staff. Holly Lodge DS0000024971.V333038.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, 10 Quality in this outcome area is good. The improved care planning and monitoring provides staff with the information they need to adequately meet residents needs. There is good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being generally well met. The home is committed to continue to improve the arrangements for administration of medication, which will safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are new format printed comprehensive care plans in place for each resident. These include personal care needed, physical wellbeing, and very well recorded, descriptive personal preferences. An example from the care plans sampled states the resident likes to get up at 8.00 am, go to bed at 8.30 pm, has 6 pillows, likes early morning tea, which is not too weak, not too strong, and without sugar. Needs the assistance of one carer, and chooses to have a bath on Thursday evenings. In addition oral health, foot care, mobility and dexterity, falls, continence, social interests, hobbies, religious, cultural needs Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 12 and personal safety and risk elements are included. This plan has a comprehensive record of all prescribed medications, which includes the reasons for each item. The residents daughter and staff have signed and dated the care plan, which also contains monthly reviews. There is evidence that care plans are generally developed and agreed with residents and where appropriate their families. For example one person has disagreed with part of the care plan and requested that a preference, liked a drink of brandy, was removed. Another care plan has been amended because the resident states she can manage her own continence needs on good days. There is a format for recording comprehensive care for people with diabetes, however not all information has not been completed on one of the sample of plans seen. There is good written evidence of a range of risk assessments, dependency levels, for falls, for moving and handling, Waterlow tissue viability and where this is high showing which equipment is in place. One person also needs bedrails and there is a written risk assessment in place. There is generally good evidence of health care services, one residents case file contains a request for new Zimmer frame, which has been provided and another has written evidence of intervention of medical services six times since March 2007. The registered manager has implemented food intake charts, though on examination these are not always fully completed. There is insufficient evidence that two residents with poor appetites are offered several small nutritious meals throughout the day. There is no evidence that the meals are fortified for extra calorific content. One resident admitted in November 2006 has a recorded weight loss of 1stone, 12 lbs and the case file has no documentary evidence of referral to community dietician, for advice and support. Discussion has taken place about the services offered by Dudley Community Dieticians, based in Amblecote High Street. The contact details of Lisa Pearce, Tel. 01384 361300 have been given to the registered manager. She is advised to make individual referrals for residents and to request general support and staff training relating to the nutritional needs of older people. The medication policy and procedures have been expanded, however further work is needed to reflect good practice guidance and the registered manager is advised to take account of guidance published by the Royal Pharmaceutical Society of Great Britain and the CSCI pharmacist as discussed during this visit. There is evidence that where the medication system is in need of action the management are wiling to work towards improvements. The registered manager has arranged medication awareness training, which has taken place for half the staff team and other half are due to attend a training session on 4 April 2007. This training has been provided by First Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 13 Response, and at present there as there is no evidence at the home of the training providers accreditation, the registered manager is advised to obtain ASET accredited medication training for senior carers responsible for the administration of residents medication. There have been improvements to the homes medication system, which include an up to date specimen signature list of staff involved in medication administration. There are now individual photos of all residents on the medication system, which provides additional safeguard against drug administration errors. The MAR sheets have been improved, with staff and witness signatures for any handwritten entries or changes made. There are examples of good practice seen during observations of the medication administration, the member of staff asked residents if they needed their prescribed pain relief and care is taken to use a non-touch technique when giving medicines. The controlled drugs register has been improved, with a separate page provided for each resident for receipt, storage, administration and disposal of controlled drugs. From observations and discussions staff show that they are aware of the need to treat residents with respect and to consider their dignity when assisting with personal care. There are residents who choose to mainly enjoy the privacy of their own rooms, which is acknowledged and respected. The collated results of CSCI residents and relatives surveys and discussions with residents during the inspection visits show that people are happy with the way that the staff deliver their care and show respect for them. Holly Lodge DS0000024971.V333038.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, 15 Quality in this outcome area is good. There are planned and spontaneous activities available on a regular basis, which give residents improved opportunities to take advantage of and develop socially stimulating activities. The majority of residents are able to maintain good contact with family and friends. Dietary needs of residents are generally catered for with a balanced and varied selection of food that meets residents tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is evidence from the service user and relatives survey forms indicating that staff listen to residents and make considerable efforts to provide a flexible service, which enables them to enjoy a good quality of life. There is a good understanding of the need to provide activities and access to social stimulation. The residents preferences for social activities, hobbies and spiritual needs are well recorded and the information is used to plan activities and events, which residents will enjoy and join in. A number of residents have enjoyed participating in the music to movement activities on the second day of this visit. It is recognised and respected that there are some people who prefer Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 15 to spend their time on their own in their own bedrooms, with individual interests or just sitting undisturbed in the quiet lounge. Information about activities, church services, outings and community events is clearly displayed in the reception area of the home. The home also has a memory board, with the date and other special events, such as the Easter celebrations. The residents currently living at the home are predominantly Christian, Church of England and though not all residents actively practice their faith, there is a monthly service at the home and a number of residents take communion. The home continues to use the services of an independent activities organiser every Monday and Tuesday providing a range of activities, including crafts and on alternate Thursdays a young man leads the residents in armchair exercises . The home has a visiting policy and visitors book, which is located in the reception area. All visitors are greeted and requested to sign in and out of the home for safety and security reasons. Visitors are welcome to visit residents at the home at any reasonable time. Members of staff are friendly and always make time to talk to visitors. A number of residents go out with their families and one person is looking forward to going out to lunch on the second day of this inspection visit. The residents are also able to go on outings to local garden centres, coffee shops and shopping centres. During the tour of the home it could be seen that residents are able to bring personal possessions to their bedroom. On the sample of residents case files, two had completed property lists that were not signed by staff, the resident or their relative. A third case file did not have a completed property list. The residents are able enjoy the flexibility of meal arrangements and to eat in their own room if they wish. A number of residents chose late breakfasts on both days of this inspection. Observations show that drinks are offered regularly, and members of staff are willing to make drinks at any time. There are plentiful supplies of cool drinks, with easy access for residents, around the communal areas of the home, which is good practice. The standard of food in the home is good quality, well presented and generally meets the dietary needs of residents. There are previous outstanding requirements to produce the menus in alternative formats, with all meals including supper and snacks included, to enable all residents to make meaningful meal choices. Holly Lodge DS0000024971.V333038.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, 18 Quality in this outcome area is good. There is evidence that any complaints and concerns are listened to and action is taken to look into them, and there are systems to record any investigations and outcomes. There are improved arrangements for protecting residents, although policies, procedures, guidance and staff training have not been fully implemented in order to provide residents with safeguards from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has complaints procedure displayed in various areas throughout the home. The registered manager states that the home has not received any complaints since the last inspection in November 2006. There is evidence from discussions that people are aware of how to raise any concerns and are confident that these will be dealt with informally if and when they arise. The previous recommendations that the responses to residents surveys are discussed at residents meetings and that the complaints procedure be produced in alternative formats suitable for residents, such as large print have not yet been actioned, though the registered manager plans to take action, when managerial time can be identified. The home has not received any allegations relating to abuse of vulnerable residents since the last inspection in November 2006. The registered manager has obtained a copy of the multi-agency procedures for the protection of Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 17 vulnerable adults, Safeguard and Protect. There is some evidence that staff are aware of its existence, though no one has yet read it and there are no signatures on the signature list. Discussion has taken place with the registered manager relating to her plans to disseminate information about this and other important policies and procedures. She has not yet implemented a staff supervision system, though she has identified a supervisory skills training course for senior carers to attend. It is recommended that supervision session should commence with the introduction and implementation of the safeguarding procedure. There is evidence of progress to provide all staff with suitable adult protection training. Holly Lodge DS0000024971.V333038.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, 21, 24, 25, 26 Quality in this outcome area is good. There are significant and positive changes to the décor and furnishings. The incremental improvements contribute to creating a pleasing and pleasant environment for residents to live in. The grounds are maintained to provide a generally safe and pleasant outdoor environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holly Lodge has two distinct areas, the Old House and the linked New House. The interior of the home is a bright, cheerful and homely. There are attractive, and generally well-maintained gardens, with some garden furniture for the residents comfort and enjoyment. The registered manager has made a bid for one off funding from the Department of Health to landscape the front enclosed garden, to provide residents with a more accessible area with raised flowerbeds and sensory gardens. Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 19 The home has a very supportive part-time handyperson, often willing to work extra time to complete tasks and he is willing to called for out of hours assistance. The tour of the home shows improvements are in progress with work in progress to rewire the Old House as a result of the five yearly fixed wiring checks. Specially made radiator covers have been ordered and are due to be put in place in the next few weeks as and when electrical work is completed. Other renewal and maintenance work is scheduled to take place following completion of the rewiring work. Example are the noisy and even floorboards and some floor coverings in the Old House and the threadbare stair carpet in the New House. A sample of residents bedrooms has been viewed with their permission. All are attractively decorated and personalised according to individual preferences. The majority have many family photographs and ornaments. Some bedrooms on the second floor have especially pleasant views across the countryside. Residents say that they are comfortable; the home is clean, warm, well ventilated, and well lit. There are two spacious lounges; a small quiet lounge and a dining room and residents are able to generally sit where they wish. There are five large double glazed windows in the conservatory, which are badly misted and detract from this attractive area. It is noted that the kitchen area has been refurbished and is well organised, clean and tidy. The Local Authority Environmental Services inspected the main kitchen on 15 November 2006 and there is satisfactory evidence of compliance for the one requirement and one recommendation in the EHO report. The small laundry has been refurbished and improvements have been made to this area. The laundry procedure and infection control guidelines are now displayed in this area to promote good infection control measures. Holly Lodge DS0000024971.V333038.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): 27,28,29,30 Quality in this outcome area is adequate. Staff morale and confidence is good. Although improved staffing levels mean that there are still insufficient dedicated care staff on at all times during the day, especially in the evenings, posing a risk that residents may not have all care, support and needs for stimulation met. The staff recruitment processes are not entirely satisfactory, which has the potential for residents to be exposed to risks of harm. The registered manager still does not currently have sufficient time to demonstrate a commitment to staff training, support and development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The structure of the staff team is: registered proprietors, registered manager and deputy manager, assistant deputy manager, 19 care staff and 3 ancillary staff. There are currently 20 residents accommodated, with a variety of dependency levels and diverse needs. Although there is now documentary evidence that the registered manager / deputy manager reviews residents dependencies and occupancy levels, however there is no documentary evidence that the information is currently used to review staffing levels, making appropriate adjustments, with the use of a recognised staffing tool, such as the Department of Health Residential Forum staffing Tool. Discussion of residents Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 21 assessed dependencies had taken place and further information has been provided to the home following the inspection visit. Assessment of copies of current rotas obtained during visit are not sufficiently detailed to show the total hours worked by each member of staff or the totals of managerial, care, catering and ancillary hours provided. The assessment of staffing rotas, discussions and observations indicate that there are 5 care staff on duty from 08:00 till 12:00 and 3 carers until 16:00 hours and 3 carers until 22.00 hours. However one member of care staff undertakes on-going laundry duties and in addition one member of care staff is also undertaking catering duties for breakfast between 8:00 - 9:00 am. During the night there are 2 waking staff on duty. There are 2 cooks working on a rota basis from 09:00 to 3:00 pm to cover each day and domestic staff are employed to cover the 7 days each week from 08:00 till 12:00 MD (or 1:00pm). Members of care staff undertake catering and laundry duties during the afternoons, and this continues to deplete dedicated care hours available for residents. A response from the CSCI relatives survey indicates that more care staff should be available to meet residents needs. There are no staff vacancies at present, though one member of care staff is leaving to pursue a different career in the near future and the assistant deputy manager is currently away, recovering from a health problem. The registered manager has recruited 3 new staff since the last inspection in November 2006. There will also be an addition person, working weekends, due to commence employment at the home when all clearances have been received. Assessment of the 3 new staff files show that there is an improvement with a recent photograph on each staff personnel file. However the staff files would benefit from reorganisation, with indexes and dividers. Although all files contain an application form, the design does not allow the applicant to complete a full employment history. The form should either request the full employment history or additional employment history or CV. Form. From assessment of two staff files it is not possible to determine whether there are any gaps in employment, which would need to be explored and reasons documented. All files contain written references, though it is not always clear if the referee is the last or most recent employer, relating to care. Files do not all contain documentary evidence of the persons identity. There is evidence of good practice obtaining POVA and CRB clearances prior to employment. The staff files provide good evidence that new employees have commenced Skills For Care inductions and are undertaking basic mandatory training. First Aid training is booked for 16 April 2007, moving & handling due on 21 May 2007, food hygiene on 15 May 2007 and 2 fire training sessions and drills have taken place since last inspection visit in November 2006. In addition 5 care staff are registered on accredited dementia course, Yesterday, Today and Tomorrow at Dudley College. Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 22 Although the registered manager currently has more managerial hours, evidence shows that she still does not have sufficient managerial time to supervise, monitor and provide staff development opportunities. The home at the last inspection in November 2006 had 9 out of 20 (45 ) of care staff qualified with an NVQ 2 award. Currently there are 9 out of 23 care staff with the NVQ 2 Award, although there are 4 candidates due to register for training for the Award with the Local Authority, this does not demonstrate compliance with the national minimum standard, which sets as a minimum a ratio of 50 of care staff with an NVQ 2 award by 2005. The homes training needs analysis and training plan and individual staff training profiles have not been seen at this visit and the manager has agreed to send completed documentary evidence to the CSCI office, Halesowen. There is verbal evidence that generally staff are knowledgeable about what residents needs are and how to meet them and there is a warm rapport with both residents and visitors. Staff feel that there is good team spirit and that they are aware of their responsibilities, and know what is expected from them. Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is good. The registered manager still does not have sufficient time to develop the service to its full potential. There are systems for resident consultation at Holly Lodge, and there is evidence that efforts are made to ensure that residents’ views are informally sought and acted upon. The standards of record keeping and health and safety compliance have improved and provide better protection for residents from risks of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 24 Paula Hubble is the registered manager at Holly Lodge and has worked at Holly Lodge for more than 17 years. She has achieved the NVQ level 4 Award in Management and Care. She has not achieved the RMA (Registered Managers Award) however she states that she is exploring options with various training providers and plans to register as a candidate in the next few weeks. As previously highlighted the registered manager and deputy manager, still do not have sufficient time to develop the staff and service to meet and exceed the Legislative framework and National Minimum Standards. During discussions there is evidence of an open, approachable ethos, which encourages good communication with residents, relatives and staff. The manager and deputy manager are committed to identify time and opportunities to develop a revised quality assurance programme, which is based on monitoring the homes performance against the National Minimum Standards for Older People. The annual development plan is in the process of development for the forth-coming year and there is verbal evidence of planned improvements to the environment of the home. Residents and relatives questionnaires have been used in July 2006 to seek their views the collated results are generally very positive, with the only area of weakness being the menus. The questionnaires to obtain feedback from other stakeholders, such as district nurses, GPs and Social Workers have not yielded any responses to date. The registered proprietor usually visits the home regularly, however he is out of the country for an extended period. He has formally notified the CSCI and made suitable arrangements with his partners in the business to undertake Regulation 26 visits and reports regarding the conduct of the home until his return. Although the manager aims to hold residents meetings every three months, these have not taken place since the last inspection visit in November 2006. It is strongly recommended that the registered manager should devise and display a schedule of residents meetings, together with agendas and minutes of meetings to encourage participation. There are staff meetings, it is stated that they are irregular and there are no current minutes available. The registered manager must aim to hold six staff meetings each year. There is insufficient evidence of the required development of a structured formal staff supervision system, with a minimum of 6 recorded one-to-one meetings with each member of staff, each year. The registered manager has sourced a supervisory training course for the senior carers to equip them to provide supervision for the care assistants. This are plans for seniors to attend the training to give them the supervisory knowledge, skills and confidence. The registered manager has devised a paper format to record supervision sessions. Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 25 There are some significant improvements to records, which include the wellcompleted pre-admission proformas, comprehensive and descriptive care plans, and daily records, and risk assessments, though there are still records requiring further improvement such as staff records. The random assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. The home is in the process of obtaining an Asbestos risk assessment from a competent source. There is generally satisfactory evidence that mandatory training is being sourced and provided for all staff on an on-going basis. There have been 10 recorded accidents involving residents since November 2006, which is a significant reduction from the previous six months. The registered manager has a system for auditing accidents involving residents, however this does not yet incorporate effective analysis of any trends or high risk issues and an evaluation of control measures, and show that any additional controls have been implemented. For example one resident at high risk of falling has had a number of falls recently and there is insufficient evidence to show that written risk assessments have been reviewed or additional measures considered. During the visit staff have been observed to use wheelchairs with footplates attached and during discussions the manager has been advised to ensure that staff understand footplates must be used on wheelchairs when transporting residents to avoid accidents. Holly Lodge DS0000024971.V333038.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 X 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X 3 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Holly Lodge DS0000024971.V333038.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 OP7 Regulation 15(1) Requirement 1) Monthly reviews must be recorded and include signatures from the people involved including the service user. (Timescale of 01/06/06 and 01/01/07 Not Fully Met) 2) To complete care plans for short term care needs such as need for infections, antibiotics etc. (Timescale of 01/06/06 and 01/01/07 Not Fully Met) 3) To develop diabetic care plans with fuller detail of diet, foot care, skin care, oral care, eye care (Timescale of 01/06/06 and 01/01/07 Not Fully Met) 2 OP8 13(4) To ensure that the following are documented as part of each residents case file / care plan 1) Plan of any pressure relieving prevention, such as turns, change of position, mobilising (Timescale of 01/06/06 and 01/01/07 Not Fully Met) Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 28 Timescale for action 01/06/07 01/06/07 2) Nutritional screening assessment and referrals to GP and / or community dietician as needed (Timescale of 01/06/06 and 01/01/07 Not Fully Met) 3) Daily records of food and fluid intake for residents with poor appetite or who are nutritionally at risk (Timescale of 01/06/06 and 01/01/07 Not Fully Met) 4) Evidence of referral to community dietician for residents with poor appetite or who are nutritionally at risk, with documented outcomes (Timescale of 01/06/06 and 01/01/07 Not Fully Met) 3 OP9 13(2) 1) To review and expand the homes medication policy and procedures, taking account of current guidance from the Royal Pharmaceutical Society of Great Britain, to include: fire precautions relating to any use of oxygen, covert medication, drug errors (always seek medical advice and Reg 37 notification to CSCI), homely remedies Further expansion needed. (Timescale of 01/01/07 Not Fully Met) 2) To ensure staff signatures are obtained to demonstrate awareness and compliance with medication policy and procedures (Timescale of 01/01/07 Not Fully Met) 3) To ensure the administration of creams, sprays etc are recorded on MAR sheets (or other appropriate recording Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 29 01/06/07 system) or code entered for non administration (Timescale of 01/01/07 Not Fully Met) 4) To record carried forward balances of medication on MAR sheets (Timescale of 01/01/07 Not Fully Met) 5) To undertake regular documented internal audits of the medication system, recording any remedial actions taken (Timescale of 01/01/07 Not Met) 4 OP9 13(2) 1) To obtain copies of the Pharmacy providers quarterly medication audits 2) To ensure the pharmacy provider places labels with instructions on actual containers, creams etc. not just on the paper bag used for delivery 5 OP14 17(2) To ensure that all residents 01/06/07 property inventories property are fully completed on admission with clothing, furniture, valuables, hearing aids etc. and thereafter kept up to date, signed and dated by staff, resident and / or relative. (Timescale of 01/12/06 Not Fully Met) 1) To develop and display menus in formats suitable to the residents capabilities (Timescale of 01/02/07 Not Fully Met) 2) To include supper choices on menus and food records (Timescale of 01/02/07 Not Fully Met) 01/06/07 01/05/07 6 OP15 17(2) Sch 4(13) Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 30 7 OP16 22 1) To produce the complaints procedure in alternative formats suited to residents needs and capabilities (large print etc.) (Timescale of 01/02/07 Not Fully Met) 2) To discuss the collated results of the CSCI service user surveys in residents / relatives meetings to ensure awareness of the homes complaints procedure (Timescale of 01/02/07 Not Fully Met) 01/09/07 8 OP18 13(6) To ensure all staff receive effective training relating to the protection of vulnerable adults 1) To replace the threadbare stair carpet in the new house within an identified timescale (Timescale of 01/02/07 Not Fully Met) - planned following rewiring 2) To replace the floor covering in bathroom in Old House following rewiring (Timescale of 01/02/07 Not Fully Met) planned following rewiring 3) Continue to replace / repair the loose and uneven floorboards, especially 2nd floor in Old House, following rewiring (Timescale of 01/02/07 Not Fully Met) - planned following rewiring 4) Ensure door wedges are not used to prop open doors (Timescale of 01/02/07 Not Fully Met) 5) To replace the dining room furniture (Timescale of 01/02/07 Not Fully Met) - 01/09/07 9 OP19 23(2) 01/09/07 Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 31 planned following rewiring 6) To replace the threadbare stair carpet in New House, within an identified timescale, (Timescale of 01/02/07 Not Fully Met) - planned following rewiring 7) To ensure proposed changes to laundry room are included in the renewal plan (Timescale of 01/02/07 Not Fully Met) planned following rewiring 10 OP19 23(2) To repair or replace the 5 large double glazed window panes in the conservatory, which are compromised 01/09/07 11 OP26 13(4) 23(2) To identify a timescale in the 01/09/07 refurbishment, renewal programme for the replace of carpets in bathing and toilet facilities with appropriate flooring for effective infection control (Timescale of 01/02/07 Not Fully Met) - planned following rewiring 1) The registered manager must submit to the CSCI Office, Halesowen formal staffing proposals, using a recognised staffing tool (such as DOH Residential Staffing Forum staffing tool for older people), taking account of current residents occupancy and dependency levels, with staff rotas, demonstrating that staffing levels are adequate to meet residents care needs (also detailing ancillary duties undertaken by care staff) (Timescale of 01/12/06 Not Met) 01/06/07 12 OP27 18(1)(a) 9(1) Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 32 2) To increase the number of care staff to provide sufficient numbers of suitably qualified, competent and experienced care staff at all times that is: a minimum of five dedicated carers (including a senior) 08:00 hrs 16:00 hours, and four carers (incl designated senior carer) 22:00 hrs - 08:00 hours (night hours) two wakeful care assistants, one of whom is designated as a senior carer. (Timescale of 01/12/06 Not Fully Met) 4) To ensure staffing rotas include total care hours each week, clearly showing total of hours worked for each member of staff and in what capacity (i.e. ancillary duties, such as laundry and catering must be identified on each shift (Timescale of 01/12/06 Not Fully Met) 13 OP28 18(1)(c) To implement a strategy to ensure that the home achieves a 50 ratio of care staff with NVQ 2 or equivalent qualification within an agreed timescale 1) To ensure that application are expanded and all forms are completed with a full employment history and any gaps in employment history are fully explored and reasons documented and checked wherever possible 2) To ensure that there are 2 satisfactory references, dated, signed and authenticated prior to commencing employment 3) To provide an accurate job description on each personnel Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 33 01/09/07 14 OP29 19(1) 17(2) Sch 2&4 01/06/07 file 4) To ensure all staff files contain evidence of the persons identity 5) To ensure the contract of employment / terms & conditions accurately reflects the post identified on the staff rota (e.g. carer being used as a senior carer) 6) To ensure that there is a copy of the hairdressers and independent chiropodists POVA/CRB clearance on file 7) To ensure that there are copies of the private Chiropodists or other therapists qualifications, public liability insurance and POVA/CRB clearances 15 OP31 9(1) 1) The registered provider must ensure that the registered manager has access to regular documented professional supervision, support and development (Timescale of 01/12/06 Not Met) 2) The registered manager must make a commitment to achieve the RMA (Registered Managers Award) within an agreed timescale (Timescale of 01/12/06 Not Fully Met) 16 OP33 24 The home must introduce a quality assurance system. (Timescale of 03/03/05 and 01/06/06 and 01/03/07 In Progress - Not Fully Met) To forward copies the following DS0000024971.V333038.R01.S.doc 01/06/07 01/07/07 17 OP33 24 01/07/07 Page 34 Holly Lodge Version 5.2 to the CSCI office, Halesowen 1) The collated results of the homes service user / relatives surveys (Timescale of 01/01/07 Not Fully Met) 2) The collated results of the homes stakeholder surveys, when completed (Timescale of 01/01/07 Not Fully Met) 3) An annual schedule of a minimum of 6 staff meetings, ensuring agendas and minutes are displayed in the home to encourage attendance (Timescale of 01/01/07 Not Fully Met) 18 OP36 18(1)(c) 1) To progress the implementation of the staff supervision system, ensuring that each member of staff has a minimum 6 formal recorded supervision sessions in each 12 months (Timescale of 01/01/07 Not Fully Met) 2) To devise an annual schedule of supervision sessions, displayed to encourage participation (Timescale of 01/01/07 Not Fully Met) 19 OP38 13(4) 17(1)(2) 1) To provide accredited / 01/09/07 approved risk management training for the registered manager and any other person undertaking risk assessment processes at the home or engage the services of a ‘competent’ person to provide documented risk assessments, with control measures and risk management strategies. (Timescale of 01/03/07 Not Met) 01/09/07 Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 35 2) To provide recognised accredited Health & Safety training for the person designated to be responsible for Health & Safety at the home or engage the services of a competent person / organisation 20 OP38 12, 13 A 5-year electrical wiring certificate must be provided. Rewiring in progress (Timescale of 03/03/05 and 01/06/06 Not Fully Met) To forward copies the following to the CSCI office, Halesowen 1) Asbestos risk assessment - In Progress (Timescale 01/01/07 Not Fully Met) 22 OP38 13(4)(c) To ensure that staff attach footplates to wheelchairs when transporting residents to avoid accidents 01/05/07 01/09/07 21 OP38 13(4) 17(1)(2) 01/06/07 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 OP9 Good Practice Recommendations That all medication in original containers is dated when opened so that accurate audits can be undertaken Not Fully Met That staff signatures are obtained to demonstrate that they have read and have an awareness of the homes and the multi-agency procedures for the protection of vulnerable adults Safeguard & Protect - In progress That staff files are reorganised and indexed for easier DS0000024971.V333038.R01.S.doc Version 5.2 Page 36 2 OP18 3 OP29 Holly Lodge monitoring and auditing 4 OP30 That dates are entered onto the training matrix rather than ticks to demonstrate up-to-date training has been received - In progress That the registered manager should devise and display a schedule of residents meetings, together with agendas and minutes of meetings to encourage participation That the accident analysis is expanded to reference residents and highlight any trends or increased risks with details of remedial action or additional control measures 5 OP33 6 OP38 Holly Lodge DS0000024971.V333038.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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