CARE HOMES FOR OLDER PEOPLE
Hollydene EMI Rest Home 46 York Road Southport Merseyside PR8 2AY Lead Inspector
Mike Perry Unannounced Inspection 30th January 2006 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 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.V280661.R01.S.doc Version 5.1 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 534539 Hollydene Care Ltd Ms Helen Caul Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 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 14.7.05 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 for caring 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. The registered manager is Helen Caul and the Registered Provider is Hollydene Care Ltd and the Responsible Person is Mr Tyfun Yilmaz. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 2 days [10 hours in total]. It was an unannounced visit and was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. There are ‘core’ standards that are inspected over the 2 inspections. Most of these were assessed on the inspection in July 2005 and this inspection concentrated on the remaining 5 standards although requirements left over from the last inspection were also reviewed. This report should therefore be read in conjunction with that report. The inspection also included the investigation of issues arising from a complaint and the basic details of the complaint and the outcomes together with requirements and recommendations are included in this report. A partial tour of the home was conducted. Care records and other care home records were inspected. The deputy manager and 2 care/ ancillary staff were spoken to. The manager was spoken to at a later date. Residents were spoken to and observations were made of their general condition. One visiting relative was interviewed. What the service does well:
The staff are continuing to review care with relatives and the feedback regarding this was positive. Key staff hold care meetings with relatives so that they can feel more involved. The relative interviewed on the inspection was also very positive about staffs’ attitude to the privacy afforded when visiting. Staff interviewed were aware of the principals involved in ensuring privacy for the residents and were able to talk about this to the inspector. The staff try hard to ensure that residents are able to choose for themselves whenever possible and exercise some control over their day. This is a difficult balance to achieve given the lack of mental capacity of the elderly resident group. Some examples of this are the staffs awareness of individual residents
Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 6 likes and dislikes in terms of dress and food preference. Individual bedrooms displayed photographs and ornaments, which reflected individual’s history and personality. One care staff described how she assisted residents to get ready for the day each morning and understood the need for time to chose preferred clothing. Staff training was discussed. The deputy manager is responsible for organising this and the existing and projected training plan for the home was discussed and meets most of the staff requirements. Recommendations for training following this inspection will be added to the programme. The ratio of NVQ trained staff in the home is good. Helen Caul is the Registered Manager of the home. Helen has just completed the Registered managers Award at level 4 NVQ. She has displayed a positive attitude to previous requirements and recommendations made by CSCI and needs to continue to do this in liaison with the Provider. There are a number of outstanding issues from previous inspections that remain [as well as the issues from this inspection] and that need some positive direction. Helen has delegated more responsibility to care staff and this process should also continue. What has improved since the last inspection? What they could do better:
On the last inspection there had been a requirement to include all relevant care in the care plan for residents so that both care staff and relatives are aware of the care to be carried out and any issues are continually evaluated. It was disappointing that some care plans are still lacking in appropriate detail
Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 7 For example there are currently residents in the home that have bedrails fitted. For one resident staff were not sure why this was so. There was a statement in the care notes to put up bedrails but no risk assessment or entry on the care plan to explain why. Also one resident was reviewed in terms of the plan of care around the management of diabetes. Although referring in general terms to the over all management of diabetes the risk factors regarding the history of poor diet compliance was missing from the care plan. The importance of any missed meals was therefore not emphasised for staff. The care plans do contain information that is not particularly relevant to individual residents care. For example two of the care plans contained a reference to ‘breathing’ but there were no needs in this area and these entries can perhaps serve to distract from the key needs. Shared bedrooms in the home were inspected and still do not have adequate screening to ensure privacy for residents. [One bedroom had no screening available]. This was a recommendation of the previous inspection and needs urgent consideration. The outline details of two complaints received by the Commission regarding care standards in the home are included in this report and the Provider and Manger need to now action the requirements and recommendations listed as a result. There remains an outstanding requirement from the previous inspection that still need to be actioned. For example the Provider must carry out an assessment for disabled access to the home and action the provision of ramped access to the home. The management of the laundry was looked at on the inspection and there are some requirements and recommendations made so that the risk of cross infection from dirty laundry can be reduced. The heating in the home was reported to be generally satisfactory although on the day of the inspection some residents reported feeling cold in the main lounge. There were no thermometers in day areas or bedrooms and this is recommended so that staff can monitor temperatures. Both lounges were seen on the visit. There were 24 residents in the home and the number of chairs in the lounges [including those in the dining room] was 19. There were therefore not enough chairs for all residents to sit in. The provision of seating for residents in both main lounges needs to be further assessed in the light of the comments in this report. There were 24 residents in the home at the time of the inspection and there were 4 care staff. Care staff were also involved in laundry and some kitchen
Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 8 duties in the afternoon. Some staff comments were received indicating that at times staffing numbers are not always consistent and care work can be very pressured and staff get frustrated that they cannot always achieve the standard they would wish. The lack of ancillary staff cover, particularly in the afternoons can mean that at teatime there is only 3 care staff to see to the needs of residents at a critical time of the day. There was some discussion over the need to rationalise staffing so that shortages are covered and not left. The reporting of accidents to relatives and the recording of this in the records needs to be reviewed in the light of the findings following the complaint investigation. The homes policy could be made more explicit in that all accidents should be reported to relatives and a note of this made either as part of the accident report format or in the care notes [or both]. The manager assesses the general environment for any hazards or risks. There are some recommendations around the possible risk to residents when using the rear fire exit route. Wiring the fire exit door into the alarm system would be the ideal for this client group in terms of negating any risk. The fire records were discussed and seen. A list of fire schedules and frequency of testing was left with the staff responsible so that the emergency lighting and fire extinguishers can be checked and a record made as indicated. One of the bedroom doors was noted to be not closing on its rebate [the self closure was missing] and must be attended to [staff made aware]. This indicates that assessments and checks need to be carried out more regularly. Staff advised that legionella risk has been assessed but there were no records available for this. 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. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 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.V280661.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed. EVIDENCE: Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 Residents have care plans but these do not always contain all of the relevant detail regarding the care for residents so that some important care needs are not emphasised or evaluated and may be missed. The right for residents privacy is understood but the lack of appropriate screening in shared bedrooms still needs to be considered and necessary action taken to safeguard residents privacy in these rooms when carrying out personal care. EVIDENCE: On the last inspection there had been a requirement to include all relevant care in the care plan for residents so that both care staff and relatives are aware of the care to be carried out and any issues are continually evaluated. It was disappointing that some care plans are still lacking in appropriate detail Currently 2 residents in the home have bedrails. For one resident staff were not sure why this was so. There was a statement in the care notes to put up bedrails but no risk assessment or entry on the care plan. The second resident
Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 12 had a risk assessment completed, which stated ‘restricted mobility’ as the reason for needing bedrails. There was no entry in the care plan for either resident as to the use of the bedrails and consequently the use of the bedrails had not been reviewed. One resident was reviewed in terms of the plan of care around the management of diabetes. The care plan did refer to the liaising with the district nurses and the role of staff regarding blood sugar monitoring. There were risk factors recorded in assessments regarding the history of poor diet compliance for this resident which was an important factor but was missing from the care plan. The importance of any missed meals was therefore not emphasised for staff. There was some discussion around the need for all relevant risk factors assessed to be considered on the plan of care. The care plans do contain information that is not particularly relevant to individual residents care. For example two of the care plans contained a reference to ‘breathing’ but there were no needs in this area and these entries can perhaps serve to distract from the key needs. The staff are continuing to review care with relatives and the feedback regarding this was positive. The relative interviewed on the inspection was very positive about staffs attitude to the privacy afforded when visiting. Staff interviewed displayed positive attitudes and were able to verbalise the importance of this. Shared bedrooms in the home were inspected and still do not have adequate screening to ensure privacy for residents. [One bedroom had no screening available]. This was a recommendation of the previous inspection and needs urgent consideration. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home is able to demonstrate an understanding of need for residents with dementia to exercise some control over their lives so that their rights are respected. EVIDENCE: The personal exercise of choice and control over resident’s daily life in the home is a difficult balance to achieve given the lack of mental capacity of the elderly resident group. There were examples however of how the home were trying to achieve a good balance. For example staff interviewed were aware of individual residents likes and dislikes in terms of dress and food preference. Individual bedrooms displayed photographs and ornaments, which reflected individual’s history and personality. One care staff described how she assisted residents to get ready for the day each morning and understood the need for time to chose preferred clothing. Some care staff commented that work can be very rushed, particularly in the morning but there was an awareness of he need to give appropriate time for residents during these periods. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected. The home must now act on the findings of the two complaints outlined so that residents care standards are maintained. EVIDENCE: The complaints process in the home was not inspected on this visit. There was however the outcomes of two complaint investigations to consider and these are outlined below. There have been 2 complaints since the last inspection. The Commission [CSCI], following the adult protection policy and working in conjunction with Social Services and the Police, have investigated both of these. The first complaint concerned the care of a resident who had been admitted for a period of respite care. The complaint was from the family who listed 13 elements in the complaint centring on the care of this resident. Following the investigation 10 elements were upheld and 3 were inconclusive. There were 8 requirements made [not listed at the end of this report]. These were around failings in: • • • • • • • Ensuring correct clothing Management of pressure sores Management of risk Keeping of medication records Training of staff around Parkinson’s disease Review of ongoing needs and keeping care plans up to date Referral for medical opinion.
DS0000061914.V280661.R01.S.doc Version 5.1 Page 15 Hollydene EMI Rest Home The second complaint was investigated as part of this inspection. The issues were around the care of a resident in the home and the management of two consecutive admissions to hospital. The complaint came from the resident’s family who listed the following concerns: 1. Resident was admitted to casualty following a fall, which resulted in fractured shoulder. No explanation had been given as to how the accident happened. 2. After the event, the relative was advised that the accident had occurred some 3 hours following the incident, which was, in the relative’s opinion to late. 3. On discharge the relative had raised concern about the lack of bedrails on the bed and was advised that the bedrails were available but could only be used if the district nurse gave her agreement. 4. Concerns about soiled sheets and continence products being carried, uncovered, through the home [particularly the dining room]. 5. Residents were sitting on the lounge coffee table as there were to few seats for residents. 6. The resident was also hypothermic on admission to casualty. 7. The complaint raised issues around the homes management of diabetes and these were reviewed again on the CSCI inspection. Three of the elements were upheld [2,4,5], one partly upheld [7], two were not upheld [1,3], and one was unresolved [6]. An additional finding was that the standard of recording of events in the care notes was poor. There are numerous examples of staff relaying information during the investigation but none of this is recorded in the care notes. The manager was open a helpful during the investigation of the complaints. There were 3 requirements made and 6 recommendations and these are listed at the end of this report. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 16 Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,25,26 The provider is gradually upgrading the home but some of the work has not met agreed time schedules and remains ongoing, which is disappointing. There is a need to attend to these Requirements so that residents can be sure of a safe well-maintained environment. EVIDENCE: There remains an outstanding requirement from the previous inspection in that the Provider must carry out an assessment for disabled access to the home and action the provision of ramped access to the home. On this inspection the access remains the same to both the front and rear of the building. There is evidence of some ongoing maintenance in the home. For example the rear corridor area outside bedrooms on the ground floor was in the process of being decorated and the boiler was being serviced. Other plans for the upgrading of the home such as the laundry provision, which has also been a previous requirement, is now due to start.
Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 18 On the inspection visit the staff described the routine of the collection of laundry from bedrooms. In the case of the upstairs bedrooms linen is collected and taken down in the lift or carried down the stairs and out through the back of the building to the laundry. In the case of the rear GF bedrooms the linen is carried through the dining room and then out through the rear of the building. Staff advised the inspector that linen bags are colour coded and should be sealed. Incontinence products should likewise be sealed in a bag although the observations of one relative [complaint investigated on the inspection] were that this is not always consistent and occasionally unsealed bags have been observed being carried through the dining area. If the complainant had witnessed anything other than maintenance of this standard then it would need to be addressed through staff supervision. There is access to the rear of the building through the fire exit doors. In the main part of the building these lead to an internal staircase. It is possible to arrange the management of laundry collection in the future so that there is no need to take any linen etc through the main home. It requires access being made to the laundry through the existing fence in the garden. This should be planned in with the upgrading of the laundry. The heating in the home was reported to be generally satisfactory although on the day of the inspection [cold day outside –1C] some residents reported feeling cold in the main lounge. There were no thermometers in day areas or bedrooms and this is recommended so that staff can monitor temperatures. Both lounges were seen on the visit. There were 24 residents in the home and the number of chairs in the lounges [including those in the dining room] was 19. There were therefore not enough chairs for all residents to sit in. staff stated that 4 chairs had recently been condemned and were being replaced by 4 new ones. This would bring the total chairs to 23. Given that it is very rare for all residents to be seated at once [some walking around, some in bedrooms, others sat at the dining table] this would probably be enough although this would have to be reviewed in the light of the observations of one relative [complaint investigation] who has observed residents sat on the coffee table in the main lounge due to insufficient seating. There was some discussion regarding the use of the rear lounge. A dining table takes up a lot of space. This room could be better arranged as a lounge area and made more homely which would take some of the pressure off the main lounge where most residents congregate. On the visit the main lounge was full. The inspector sat on the coffee table to talk to residents. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 The staffing in the home can be stretched at times and this must be addressed by the manager and provider in terms of flexibly covering shortages with sufficient staff so that resident’s needs are consistently met. The training programme in the home is developing well although some recommended training was discussed so that staff are competent and have an understanding of all of the residents needs. EVIDENCE: There were 24 residents in the home at the time of the inspection. There was 4 care staff. The manager would normally be supernummery to these numbers but was on holiday at the time. Some staff comments were received indicating that at times staffing numbers are not always consistent and care work can be very pressured and staff get frustrated that they cannot always achieve the standard they would wish. Key to this is the lack of ancillary staff cover at critical times in the day. For example there is no staff member in the kitchen after 3pm and a member of the care staff is designated kitchen duties until 6pm. This leaves reduced care staffing over the tea time period, which can be quite demanding. To compound the problem, at the time of the inspection the laundry staff was also off sick and care staff were also involved in these duties. There was some discussion over the need to rationalise staffing so that shortages are covered and not left.
Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 20 Staff training was discussed. The deputy manager is responsible for organising this and the existing and projected training plan for the home was discussed and meets most of the staff requirements. The 2 recent complaints have raised the need for staff to receive updates in both Parkinson’s disease and diabetes so that staff are more aware of the needs of residents with these illnesses. Out of 18 care staff 11 have training at NVQ level. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The manager of the home has the experience and qualifications to ensure that Hollydene is run satisfactorily and that residents best interests are maintained. The quality systems in place ensure ongoing monitoring and improvements take place so that resident care can be progressed and procedures are appropriately managed to ensure smooth running of the home. There is some health and safety issues identified on the inspection that need to be further assessed to ensure resident safety. EVIDENCE: Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 22 Helen Caul is the Registered Manager of the home. She has been in the management role for the last 2 – 3 years in total. Helen has just completed the Registered managers Award at level 4 NVQ. She has support from a deputy manager as well as administration input to the home. Helen was not present for the inspection, which was unannounced. She has displayed a positive attitude to previous requirements and recommendations made by CSCI and needs to continue to do this in liaison with the Provider. There are a number of outstanding issues from previous inspections that remain [as well as the issues form this inspection] and that need some positive direction. There are also lessons from the 2 recent complaints that need to be reflected on. Helen has delegated more responsibility to care staff and this process should also continue. One issue looked at as part of the complaint investigation was the reporting of accidents to relatives and the recording of this in the records. Although the manager stated that staff had tried to contact and report an accident the complainant had not been informed for some time in excess of three hours following a fall resulting in a referral to casualty. There was no reference in the care records of any of these attempts nor a record of the time the relative was actually informed. The homes policy could be made more explicit in that all accidents should be reported to relatives and a note of this made either as part of the accident report format or in the care notes [or both]. The policies and procedures around the management of residents finance was reviewed with the administrator. The homes policy is for relatives to deal with residents personal allowances. There is a small float of petty cash, which is kept in a locked draw in the office. Health and safety records were reviewed. Staff have access to policies and a record is maintained of staff signatures indicating that they have been communicated. The manager organises various risk assessments of the environment, which are ongoing. One risk assessment looked at the rear GF fire exit door, which is near the GF bedrooms and opens out onto a set of stone stairs to the garden. The risk of a confused elderly person wandering out in the dark has been assessed and measures taken although the stairs are not lit very well and a halogen light above the stairs would be indicated. The fire exit doors are alarmed to alert staff if opened. Wiring the fire exit door into the alarm system would be the ideal for this client group in terms of negating any risk. The fire records were discussed and seen. A list of fire schedules and frequency of testing was left with the staff responsible so that the emergency lighting and fire extinguishers can be checked and a record made as indicated. Equipment and alarms are maintained. One of the bedroom doors was noted to be not closing on its rebate [the self closure was missing] and must be attended to Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 23 [staff made aware]. This indicates that assessments and checks need to be carried out more regularly. Other records seen included manual handling training which were satisfactory. Staff advised that legionella risk has been assessed but there were no records available for this. The bath on the top floor is not used very often. On checking the cold water tap cannot be turned on and this needs assessing as it represents a dead end, which may harbour bacteria. Gas Safety certificates and the electrical safety certificate could not be located. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 24 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 2 2 X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? 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 Requirement All care needs for individual residents must be addressed and included on the care plan. This would include specific staff role in managing diabetes and an awareness of any specific risk factors so that staff are aware. Also the management of bedrails for any resident in the home. [Last requirement date 30.1.06 not met] Timescale for action 15/05/06 2. OP19 23 3 OP20 16 The registered person must carry 15/05/06 out an assessment for disabled access and action the provision of ramped access to the home [last requirement date 1.7.05 not met. Not met on this inspection] The registered provider must 15/05/06 ensure sufficient and suitable seating for residents in the communal areas designated. The laundry must be upgraded to provide non-porous flooring and walls for cleaning maintenance. [Last requirement date of 1.9.05 was extended but
DS0000061914.V280661.R01.S.doc 4. OP26 13 15/05/06 Hollydene EMI Rest Home Version 5.1 Page 26 5. OP26 13 still no met on this inspection]. The management of dirty linen 15/05/06 must be reviewed with respect to standard 26.2 of the NMS, which states that laundry facilities are sited so that dirty laundry is not carried through areas of food preparation, storage or where people are eating. This can be achieved with the upgrading of the laundry and access being made from the rear of the building. The home must be staffed with 13/03/06 sufficient care staff and ancillary cover so that routine work can be undertaken and resident needs can be consistently met. This is particularly so from 3 – 6 pm. All fire doors must be checked so 13/03/06 that they close on their rebate. Any failure of self-closing devises must be remedied. 6 OP27 18 7 OP38 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP7 OP10 OP25 Good Practice Recommendations Care planning documentation should be reviewed as discussed so that details can be made more relevant an individualised. Serious consideration should be given to the provision of curtains in shared bedrooms as discussed to ensure privacy for residents when performing personal care. There should be thermometers in all areas of the home [day areas, bedrooms] so that minimum temperatures can be monitored. Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 27 4 OP27 There is a need for some permanent cover in the kitchen during the afternoon/ teatime period and this should be seriously considered. The homes training plan should include sessions on diabetes and its management/care and Parkinson’s disease so that staff can have a greater awareness of residents needs. The accident policy needs to be more clearly defined. It is important that a statement is included that all accidents are reported to relatives and that this is recorded. A policy on the use of bedrails should be drawn up and communicated to staff. Consideration should be given to the rear fire exit doors being wired in to the fire alarm system. Routine checks on the emergency lighting and fire extinguishers [as listed in the fire schedules supplied] should be maintained. Copies of the general electrical certificate, the legionella assessments and the gas safety certificate should be supplied to the Commission. The recording of blood sugars by staff should be in the residents care notes [perhaps on a separate chart]. This should apply to all care staff observations. Observations and events that occur need to be recorded with greater detail in the care notes. All notes should be timed as well as dated. 5 OP30 6 7 8 9 OP38 OP38 OP38 OP38 10 OP38 11 *RCN 12 *RCN Hollydene EMI Rest Home DS0000061914.V280661.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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