CARE HOMES FOR OLDER PEOPLE
Hollydene EMI Rest Home 46 York Road Southport Merseyside PR8 2AY Lead Inspector
Mr Paul Kenyon Key Unannounced Inspection 11.15 14th May 2008 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 Hollydene EMI Rest Home DS0000061914.V361859.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. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hollydene EMI Rest Home Address 46 York Road Southport Merseyside PR8 2AY 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) 01704 566846 maxine.nichol@cedarscaregroup.co.uk Hollydene Care Ltd Post Vacant Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person must at all times appoint a suitably qualified manager that is registered with the CSCI 28th June 2007 Date of last inspection Brief Description of the Service: Hollydene is a residential care home that specialises in the care of older people with dementia. The home is registered to care for up to 25 residents. The home is a large old detached house to which more modern extensions have been added to the side and at the back. There is a large enclosed garden at the rear of the home; the garden to the front has been given over to off road parking. Hollydene provides permanent residential care for its residents. It does not provide nursing care. Hollydene is established in a residential area very close to Birkdale village and railway station. Southport town centre is about 1 mile. There is no registered manager, currently Maxine Nichol manages the service in an Acting capacity although she has applied to the Commission for Social Care Inspection for registration, the Registered Provider is Hollydene Care Ltd and the Responsible Person is Mr Tyfun Yilmaz. Fees for the service currently range from £418.70 to £435 per week. Hollydene EMI Rest Home DS0000061914.V361859.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 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection of Hollydene this inspection year (April 2008 to March 2009) and was unannounced with no prior notice being given to the home that the inspection was to take place. National Minimum Standards were used to assess the quality of care provided. In addition to this, surveys returned by relatives and staff, observation of care practices and the annual quality assurance assessment were all used to measure the quality of care provided. Additionally records relating to the quality of care provided were also examined. The service provided the annual quality assurance assessment before the inspection as required by law and this provided additional information about the service. The inspection took place during the late morning and extended into the afternoon taking five hours in total. Comments from staff and relatives are included later in this report. What the service does well:
Those who use the service benefit from having their needs identified and assessed before they come to live at Hollydene. The service ensures that the health needs of individuals are met and that the management of medication is safe. The service provides activities to individuals and enables contact with their families and friends to continue. The service enables those who use the service to be as independent as possible in respect of their mobility, finances and the inclusion of personal possessions in their own living space. The nutritional needs of individuals are met. The service has a transparent complaints procedure and individuals are protected from abuse through policies and procedures, staff training and the recruitment process.
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 6 Those who use the service live in a pleasant and hygienic environment. The service has ensured that care staff levels are sufficient to meet the needs of those who live in Hollydene. The service ensures that there is an ongoing training programme for staff to best serve the needs of those who live at Hollydene. Those who use the service benefit from a clear management structure being in place in the home and ensure that management staff are on duty at all times. The health and safety of all is promoted. Comments through surveys included: ‘We always given up to date information, employment checks are carried out, induction mostly covered what was needed to do the job, training is relevant and meets needs of individuals and is up to date’ ‘We often get support from the manager, and we know what to do there are concerns, information is passed on well within the service, there is always enough staff, we always get the right support to meet different needs’ ‘Good standard of care for all service users and high standards are maintained in the home’ ‘The service maintains a high standard of care covering all aspects of the service of the service users mental health and social well being’ ‘The service treats everyone as individuals, promotes independence, gives service users support and respect and privacy and reviews care plans monthly’ ‘I always keep up to date by recording any accident happening to clients and all the reports and information that need to be recorded, I had my Criminal Records check and references checked before I started working, I have been shown all round the house and I have been taught how to set and re-set the fire alarm. I have been shown all the services policies and procedures, our manager organises staff meetings were we meet and discuss issues relating to our working environment, our manager talks to each person individually, there is always enough staff, as we work as a team we are all willing to support and encourage our service users and try to meet their needs, we provide enough material to use such as incontinence products-we could try to support as much as possible the individual and helping service users to keep going day after day, we are all happy as we are working as a team’ ‘The service gives a high care to enable people who live here and to keep their optimum state of health and well being’
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 7 ‘We get all the information we need to know if anything changes with service users’ ‘ Some of the things we learn is done as we work’ ‘the service is good at helping ’ ‘Always get enough information about their relative, feels needs are always met, always kept up with important information about their relative, relative always gets support from the service, staff always have the right skills and experience, staff meet the needs of all there, knows how to make a complaint, service has responded appropriately to concerns, service always supports relative to live the life they choose, has no complaints, does not think the home needs to improve’ ‘Even though we have only been involved in the this care home for a short time all seems ok, my mother is happy and settled, I was kept up to date with two incidents satisfactorily, the staff appear to react to my mothers needs and look after her as agreed, the care home appears to have all the skills that is required to take care of my mother, my mother appears to mix with everyone ok, the complaint procedure was shown to me on the first day, I am happy with the way the home responds, my mother is happy and content, the staff are always available and are in attendance whenever I visit, we are happy up to now’ What has improved since the last inspection?
All of those who use the service benefit from having a plan of care outlining their needs The number of care staff is now sufficient to meet the needs of those who live at Hollydene. The recruitment process now protects those who use the service from abuse. The service has now forwarded a candidate to become the Registered Manager. The safety of those who use the service is now promoted through the installation of window restrictors. Improvements have been made in respect of the redecoration some internal areas such as one of the lounges and improvements to the exterior of the house. A patio area has been created to the front of the building, which is a pleasant yet, private area. The rear garden is now being landscaped and is
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 8 almost complete. This provides a spacious, attractive and safe environment for individuals to sit in finer weather. 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. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 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 Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to Hollydene at present. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those individuals who come to live in the home have their needs assessed prior to them coming to live at Hollydene so that a judgement as to whether their needs can be met can be anticipated. EVIDENCE: Assessment information was examined relating to four individuals who had been admitted since the last key inspection. Only one of these are funded by Local Authority and a Local Authority assessment as well as a home assessment were in place for this individual. For all others who are privately funded, a home assessment had been carried out prior to them being admitted. All assessments carried out by the Acting Manager. The assessments
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 11 include reference to health care; a care needs assessment in line with mobility, continence and communication. A pressure sore assessment is in place as well as a nutritional assessment, mental health assessment that determines the level of disability the person has, a dependency, manual handling and general risk assessment. These form the basis of the care plan and are subject to review. A falls risk assessment is in place as well as information in relation to the person’s preferred social activities. Staff survey comments included: ‘Always given up to date information about people’s needs’ ‘Always given the information we need to know if anything changes with service users’ ‘ I always keep up to date’ The annual quality assurance assessment stated: ‘There is a full pre admission assessment undertaken and if required a full social services assessment. We are aware of our limitations and will decline some services users if we can not provide the care needed.’ Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All those who use the service have their needs identified in a care plan yet not all families have the opportunity to confirm the content of such plans. The health needs of individuals are met. Medication is managed in a safe manner. Care practices within the home maintain the privacy and dignity of individuals although the environment does not maintain the privacy of two individuals who use the service. EVIDENCE: Five care plans were examined, four relating to those who had come to live at Hollydene since the last inspection and one relating to a person of longer residency. All care plans are securely stored yet are accessible to the staff team. The care plan includes assessment information as outlined in the previous section of this report. A day care plan and night care plan is in place as well as a section which encourages the views of relatives on the plan. In the
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 13 latter case, keyworkers had completed this section and there was little evidence that relatives had been consulted. This is raised as a requirement in this report. The care plan covers activities of living such as the environment, communication, mobility, eating/drinking, hygiene, washing/bathing, dressing, and mental health. All were noted to have been reviewed on a monthly basis. All care plans are reviewed yet as stated do not include clear relative involvement in the contents of the care plan. Care plans provide detail and offer an overall view of the health needs, daily living needs and social needs of individuals. The annual quality assurance assessment (AQAA) stated that family involvement in care could be better. In relation to health needs, one person in the sample is identified as having a health condition. This was included in the care plan and information is provided in the kitchen area to confirm that catering staff are aware of this. This was also included within the nutritional assessment. The initial assessment for two people identified that there was a need for an optician appointment to be arranged yet there was no evidence that this has been done. The arranging of opticians appointments for these people is raised as a recommendation in this report. This person has their weight monitored appropriately and a pressure sore assessment is in place. For another individual, a pressure sore assessment had identified that this person had had a skin condition. This had since been eliminated through the care provided in the home and the involvement of District Nurses. It is recommended that a reassessment in relation to pressure sores be completed for this person. Nutritional assessments conclude for others that there is a requirement for weight to be monitored weekly. This has not occurred and is raised as a recommendation. There is evidence of health care professionals having visited individuals including: District Nurses, Doctors and opticians. All individuals sampled have been registered with a Doctor and details of their registration with various surgeries are available. There was Evidence in the activity programme of light chair based exercises and other activities having been offered throughout the week. In respect of medication, the Annual Quality Assurance Assessment states that a new pharmacy supplier has taken over supplies and this was confirmed through the examination of records. All medication systems are audited by the pharmacy supplier as evidenced through records. Medication is stored securely in portable trolley, which is tethered to the wall when not in use. A blister pack system in operation with a controlled drugs cabinet separately in place and this is secure. There was evidence that staff who handle medication have received training from pharmacy supplier as evidenced through certificates on display. No individual in the sampled risk assessments self medicate given their
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 14 disability and mental health assessments. In medication records, there were four instances of signature omissions. The Acting Manager is aware of these and is to take action. Records are available to suggest that all receipted medications are recorded. A disposal of medication book in operation. A controlled drugs register is available with only one person currently having been prescribed this type of medication. This register has the stock of medication checked daily and two signatures are present after administration. The Annual Quality Assurance Assessment stated ‘We have changed pharmacy and there are more stringent guidelines in place with more frequent visits from the pharmacy team. We do not have any service users who self medicate. In respect of privacy and dignity, all shared rooms with the exception of one are now singly occupied. One bedroom previously shared is now singly occupied and a lounge area has been created where the other bed was. Another room was viewed which is shared. Screening is provided around hand washbasins but none is provided between the beds. This is raised as a requirement in this report. Lunchtime was observed. Staff maintained a dignified approach to service users and spoke in a respectful manner at all time. Support was discreet during the meal and while providing assistance with mobility. The atmosphere was relaxed and individuals able to pursue their own activities safely. Clothing observed to be discreetly marked and stored in laundry area in separate boxes to minimise loss or the mixing up of clothing. All care plans include the preferred names of individuals as well as their ethnic background. The majority of those who use the service are white British with one person identified as white Irish. This person is Roman Catholic and has the opportunity to attend a church service as indicated in the care plan and activity record. One person is a Jehovah’s Witness. There was little evidence that staff are aware of this belief beyond the need for this person not to have blood transfusions. This is raised as a recommendation in this report. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service benefit from being provided with activities if they wish to join in and have their preferred routines respected. Individuals benefit from having links with their families and friends. Individuals are allowed to be as independent as possible and have their nutritional needs met. EVIDENCE: There was evidence in care plans that daily activities and routines are taken into account and this covers both day and night time activities. Preferred activities are also identified in care plans. An activity board is on display includes: Music, quoits, TV, cards, hairdressing, church, nail care, balloon exercise, light exercises, chair exercises quizzes. All activities on display are accompanied by symbols indicating the nature of the activity. Lounge areas are available for activities in place.
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 16 A visitor’s book is in place and this provided evidence to suggest that service users receive visitors on a daily basis. During the afternoon, some residents with a member of staff were playing a board game. This proved to be lighthearted and residents responded to the activity well. A tour of the building suggested that many residents are able to include personal items into their rooms including furniture from home and other items. The home does not deal with the finances of any residents and this is left to either families or those with power of attorney In terms of independence, many instances observed during the visit of staff enabling residents to be as independent as possible in terms of mobility and in eating. Eating will be outlined later in this section. Other residents were supported to use walking aids or to be escorted by staff yet emphasis on them being independent and not over reliant on staff. All care plans examined had a nutritional assessment. There was evidence in care plans of special diets such as those for diabetes and low fat diets. All information on dietary needs is available to the kitchen staff as well as information in respect of how food should be presented to each individual i.e. in a softer diet or partially liquidised. A menu is on display in the dining room. The dining room is a large room that can accommodate all residents. The kitchen is well equipped and has recently been inspected for food hygiene standards by the local environmental health inspectors and passed with no requirements. Stocks of food were noted to be sufficient. A kitchen cleaning is schedule in place as well as checks on refrigerator and freezer temperatures. Lunch was observed. All staff spoke with residents in a respectful manner and ensured that they were provided with meals promptly. Information was given by staff about what the contents of the meals were. No one needed direct assistance with meals apart from some prompting. Lunch was a relaxed and unhurried occasion and residents were provided with the time they needed to have their meals with some finishing sooner and others later. Attention was paid by staff to the comfort of residents at each table. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service or their families have the information they need to make a complaint. Those who use the service are protected from abuse. EVIDENCE: A complaints procedure is in place and includes reference to the Commission for Social Care Inspection and has the contact details of the local office. The procedure is on prominent display. Complaints records are maintained. No complaints or concerns have been received since before the last key inspection. Compliments are also recorded. One survey from a relative stated that they were uncertain about the procedure ‘If I wished to complain I would probably approach Age concern, the Alzheimer’s Society or health centre’: this person has some concerns but has not complained and is not aware of the complaints procedure. Another view stated: ‘I know how to make a complaint, the service has responded appropriately to concern’ and ‘the complaint procedure was shown to me on the first day, I am happy with the way the home responds’ Given the inconsistency of awareness of the complaints procedure, it is recommended that this be reinforced to relatives. In relation to safeguarding adults, a flow chart is in place for senior staff in relation to action needed if an allegation of abuse is made. A copy of the Local
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 18 Authority procedure is also available. A whistle blowing procedure is available and there is evidence that staff have signed this to acknowledge their understanding of it. Policies are also in place in relation to staff involvement in gifts and wills, restraint and action to take in instances of physical or verbal aggression. No allegations of abuse have been made since the last key inspection. Evidence was available from training records that abuse awareness training had been received by staff and is ongoing. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service live in a well-maintained and hygienic environment. EVIDENCE: A tour of the interior and exterior of the building was conducted. The exterior of building is well maintained and improvements to the exterior have been made including the creation of a patio area with seating available to the front of the building. The rear garden is being landscaped and redeveloped. Access is available to these areas for those who live at Hollydene. A tour of the interior of the building noted no offensive odours. A passenger lift is in place and this serves all floors and operates satisfactorily. A tour was made of a number of bedrooms. These included the inclusion of personal items.
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 20 Improvements have been made to the interior of the home including the redecoration of a lounge area and a new shower room created. There was evidence of refurbishment within the bedroom areas. A refurbishment list is available identifying those areas in the interior and exterior of the home that will be subject to renewal during 2008. All areas are pleasantly decorated. The dining room has been reorganised to include a lounge area and there was no evidence of poor standards of decoration. The building remains secure outside and inside to promote the safety of residents. The management of dirty laundry continues to be satisfactory. The laundry has a non porous floor and washable walls and contains industrial appliances. The home has domestic staff on duty but their role does not cover the laundering if clothes. This is part of care staff’s role. The need for a laundry assistant was raised as a requirement at the last key inspection and is raised once more. There was evidence from the staff rota that an identified member of staff is a laundry assistant but this is not consistently on this document. A staff survey also indicated the need for a laundry assistant in the home. Protective clothing is available as well as soap and towels in all areas, clinical waste system and a sluice. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 21 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): 27,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service are supported by care staff who are sufficient in number. Individuals are protected by the recruitment procedure and supported by trained staff. EVIDENCE: A staff rota is in place. This includes the designation of staff. Care plan assessments completed for all people in the sample examined indicated that the level of staff involvement in their support is identified and that recorded needs would indicate and determine staffing levels and dependency levels. The staff rota notes that there has been no change to general staffing levels and that these are maintained: Staff surveys note that they are happy with staff levels. Three personnel files examined were examined relating to those who had commenced employment since the last inspection. All showed evidence that regulations relating to recruitment had been complied with. Staff surveys noted that they considered that they received sufficient training.
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 22 A training plan is in place. This indicates training that has been done and training that needs doing or needs to be updated. Training includes mandatory training as well as other related training such as: abuse awareness, dementia awareness, continence awareness, and optical awareness. Induction records are in place on personnel files. This includes the service’s own induction in relation to orientation around the building and terms of employment but also a Common Induction standards induction booklet completed for new staff. This relates to values that should be adopted by carers. Training certificates are in place in personnel records relating to recent staffing. The Acting Manager acknowledges that some staff training needs to be updated. Hollydene EMI Rest Home DS0000061914.V361859.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 and 38. Standard 35 is not applicable since the service does not administer any monies of those who use the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service benefit from having a management structure in place. Individuals and their relatives do not fully benefit from having their views reflected. The health and safety of all is promoted. EVIDENCE: Since the last inspection, a new individual is managing the service although this person has not yet become the registered manager. This person has submitted an application form to the Commission for Social Care Inspection and an interview with the regulator is imminent. A Deputy Manager is in place as well as senior care assistants on duty at all times.
Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 24 The service utilises an external agency to assess the quality of care it provides. This process was evidenced through a certificate for 2007 yet there was further evidence that this process is to start again for 2008 and that the process is imminent. This process includes the collating of the views of all relatives, residents where possible and staff. The service co-operated with the Inspector throughout the inspection by circulating relative and staff surveys and returning the Annual Quality Assurance Assessment back within the required timescale. During the inspection full co-operation was held with the inspector being able to examine all records and observe aspects of care throughout. A requirement at the last inspection noted that inspection reports carried out by a representative of the organisations were not always being provided to the acting manager. This remains with four months reports missing for 2007. It is required that reports relating to these visits are made available to the acting manager. Training records indicated that staff had either received training in fire awareness, first aid, infection control and food hygiene or that updates had been identified and that training was generally ongoing. Records relating to the Control Of Substances Hazardous to health are in place but would benefit from being updated. This is recommended. A gas safety certificate is in place as well as an electrical certificate and a legionella assessment certificate. Radiators are covered and thermostatic valves are in situ. Water temperatures are checked regularly. Window restrictors are now in place in upper floor bedrooms. The security of the home is sufficient with the front door only to be opened with a key and all side areas are secure. Fire drills are undertaken through evidence of records as well as fire alarm and emergency lighting tests. Portable appliances are checked and accidents recorded with any incidents adversely affecting the well being of those who use the services sent through to the regulator where applicable. There is evidence of portable and fixed hoists checks being made in line with regulations. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 25 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A X X 3 Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 26 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. 2. Standard OP7 OP10 Regulation 15 12 Requirement Timescale for action 31/07/08 3. OP33 26 Evidence must be provided that relatives have confirmed the contents of care plans Screening must be provided to 31/05/08 ensure that those who use shared rooms have their privacy upheld Reports relating to monthly visits 31/07/08 conducted by a representative of the organisation must be consistently provided to the Acting Manager. PREVIOUS REQUIREMENT AT LAST KEY INSPECTION 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. Refer to Standard Good Practice Recommendations Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 27 1. 2. 3. 4. 5. 6. OP8 OP8 OP8 OP8 OP16 OP38 A reassessment should be carried out in respect of pressure sores relating to the individual identified at the inspection The monitoring of the weight of individuals should be carried out in line with nutritional assessments Appointments with health care professionals identified at assessment should be carried out. CHANGE Staff should be provided with information about the religious needs of those who use the service. The complaints procedure should be reinforced to all relatives The data sheets relating to the Control of Substances hazardous to health should be updated. Hollydene EMI Rest Home DS0000061914.V361859.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside and Cheshire Area Office Unit One 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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
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