Inspection on 07/06/05 for Holme House

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Holme House 08/05/09

Holme House 22/05/08

Holme House 30/05/07

Holme House 19/06/06

Holme House 24/10/05

Holme House 02/12/04

Holme House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Holme House Oxford Road Gomersal Cleckheaton BD19 4LA Lead Inspector Jacinta Lockwood Unannounced 7 June 2005 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 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. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holme House Address Oxford Road Gomersal Cleckheaton BD19 4LA 01274 862021 01274 871702 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Milelands Ltd Mr Jeremy Martin Care Home 40 Category(ies) of Older People 40 registration, with number of places Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 02.12.04 Brief Description of the Service: Home House is a care home registered to provide personal care and accommodation for up to forty older people. It is situated in the Gomersal area of Kirklees fairly close to Birkenshaw, Birstall and the M62. The original property has been extended and modernised for its current use. Some of the property’s original features have been retained adding to its homely feeling. There are large gardens to the front and rear of the property where service users are able to sit when the weather permits. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection carried out by two inspectors who looked at a number of core requirements and followed up previous requirements and recommendations. The following inspection methods were used: a limited tour of the building; inspection of a sample of records including pre-admission assessments, care plans and risk assessments, medication and medication policy, accident log, service user’s guide, complaints procedure and complaints file, staffing rota, staff recruitment and training records, and health and safety documentation. Discussions were held with service users, a relative, visiting district nurses, staff and management. What the service does well: What has improved since the last inspection? What they could do better: Service users must receive written confirmation that the home can meet their assessed needs. The registered provider should ensure service users have written terms and conditions with the home. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 6 Develop social care plans with service users and ensure that service users are consulted about their plan of care. Closer attention to detail should be paid to record keeping to ensure that records are fully completed and up to date. Management and staff must ensure that the home’s medication policies and procedures are followed in respect of service users who self-medicate and in relation to record keeping. Ensure that all staff have adult protection awareness training, and that robust recruitment practices are followed in order to protect the service users against the risk of abuse. Ensure that service users are protected from the potential spread of infection, toxic conditions and the risk of scalding. The registered manager must carry out his responsibilities fully regarding the running and management of the home. Completion of the NVQ level 4 qualification in care and management would support him in 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. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 8 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 standard(s) 2, 3, 6 Local authority contracts relating to service users are available, but the home does not have its own statement of terms and conditions with service users. Service users are assessed before being admitted to the home, however, they do not receive confirmation from the registered provider that the home can meet their needs. EVIDENCE: A recommendation that a statement of terms and conditions with the home be produced has not been actioned. The recommendation is carried forward. Local authority contracts were available. As stated in the home’s service user’s guide, pre-admission assessments are carried out with prospective service users. Assessments were detailed giving a good picture of service users’ level of need and independence. A social worker’s reassessment of a service user stated that the service user’s needs were well met at Holme House. The registered person must provide a letter of confirmation to prospective service users that, following pre-admission Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 9 assessment, the home can meet their needs. Service users said they enjoyed living at the home. Holme House does not provide intermediate care. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9, 10 Care plans were informative but lacked detailed about service users’ social care needs. Service users’ health care needs are met through multi-disciplinary working, involving healthcare professionals. Where appropriate, service users are responsible for their own medication, but the home’s policies and procedures for dealing with medicines are not being followed consistently. Care staff respect service users’ privacy and dignity. EVIDENCE: Care plans reflected some of the service users’ needs identified in the activities of daily living assessment completed on admission, but care plans had not been developed as to how the service users’ social care needs were to be met. It was positive to see that care plans had been developed for new identified needs and discontinued when they were no longer applicable. Staff had a good understanding of service users’ care needs. Service users spoke positively about the care provided. Care plans have been reviewed monthly, but, unfortunately, there was no evidence that the service users had been involved in these reviews as Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 11 previously recommended. A letter on one file stated that the service user did not want to be involved with reviewing their care plan. Whilst service users’ wishes should be respected, it is important that wherever able they are involved in planning and reviewing their care. Risk assessments were available, but not all identified risks had been assessed in accordance with the home’s policy and procedure. Generally there was a good level of detail in care planning and risk assessment documentation, but there were some gaps in recording information and some documents had not been dated or signed, so it was difficult to assess the currency of the information. Although a care plan noted that a service user now required a liquidised diet, the nutritional risk assessment had not been updated and neither had the aims/objectives of the care plan. Daily records should reflect delivery of the care plan, for example, where the care plan states that fluid output should be monitored. There was no evidence that service users’ weight is monitored and this should be addressed. There was evidence that healthcare professionals are involved with service users. Two visiting district nurses reported good communication and working relationships with staff who follow any advice given and keep the nurses informed of service users’ healthcare needs. They reported that infection control practices at the home have improved. As discussed with the registered manager and staff with responsibility for medicines administration, the practice of removing medication from the containers in which they are dispensed and placing them in unlabelled containers for administration by staff must stop. A sample of as required medication could not be reconciled with records held and there were some gaps in recording medicines administration. A medicine requiring refrigeration was not stored appropriately. Service users who self administer medication must have a risk assessment in place as stated in the home’s comprehensive medicines policy. Staff were observed to respect service users’ privacy and dignity as stated in the home’s service user’s guide. The majority of service users spoken to made positive comments about staff and the care provided at Holme House. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 12 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 standard(s) 15 Meals in the home are good and cater for dietary needs and individual preferences. EVIDENCE: Meals can be taken in the dining room or in service users’ private accommodation if they prefer. The registered manager said that service users are involved in menu planning and that food choices were available. Staff were heard to offer service users a choice of food. Specialist diets are catered for. A member of staff was observed to sit with a service user who required assistance to eat and assistance was provided in a sensitive manner. The dining rooms were nicely set out and service users were provided with protective clothing where appropriate. The food store was well stocked. Service users commented positively about the food provided. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 13 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 standard(s) 16, 18 Any complaints received are acted upon. Some processes are in place to protect service users from abuse, but all staff need to receive adult protection training to ensure that service users are protected from the potential risk of abuse. EVIDENCE: A complaints policy is in place and is also included in the home’s service users’ guide and displayed in service users’ bedrooms. A record of complaints is kept and shows that complaints are followed through. The registered manager explained that he and a senior carer are booked to attend adult protection training on 28.06.05. Although a staff member was aware of the action to take were abuse to be suspected, not all staff have received adult protection training. This must be addressed. An adult protection policy and procedure was in place. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 14 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 standard(s) 19, 21, 22, 24, 26 Service users live in a homely environment, where their own rooms suit their needs. Some practices are the home do not promote the health and safety of service users. Sufficient and suitable lavatories and washing facilities are provided for service users. The home is generally clean, pleasant and hygienic, but there are some areas which pose a potential health risk to service users. EVIDENCE: Service users have access to well maintained grounds with seating where they can sit in fine weather. Ramped access with handrails is in place to the front of the property. There was evidence that bedrooms are redecorated as they become vacant and new bedroom furniture and curtains installed. Redecoration was ongoing at the time of the inspection. Since the last inspection the dining rooms, Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 15 lounge, entrance hall and stairs and two bedrooms have been redecorated to a good standard. Wall mounted cupboards remain in place in bedrooms and pose a potential risk. Although foam has been placed around the cupboard corners, this looks unsightly and staff have banged their heads on them. The cupboards should be re-sited or removed as previously recommended. Call leads were in place in bedrooms, but were not always accessible to service users. Staff reported that regular checks are made on service users, however, call leads should be accessible to service users. Service users are provided with specialist equipment to maximise their independence and bedrooms seen contained service users’ personal possessions and reflected their tastes and interests. Screening is available in shared rooms to promote service users’ privacy and dignity. Generally, the home was clean, tidy and free from offensive odours, however, some bath mats were soiled with faecal matter as was the floor to a toilet area and the carpet in one bedroom was stained. A sample of water temperature checks to a bedroom, three bathrooms and a toilet gave readings of between 48 degrees and 53 degrees Celsius. These are too high and action should be taken to ensure water is delivered locally around 43 degrees Celsius to prevent risks from scalding. Mr Martin is to forward a revised action plan to the Commission for the fitting of thermostatic valves. The cellar laundry area was untidy with clothing to be washed left on the floor and tins of paint and other items being stored there. This was discussed with the registered manager and appropriate action should be taken to promote health and safety. The fire door between the dining rooms was wedged open. As discussed with the registered manager a suitable hold open device should be put in place to ensure fire safety. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 16 Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 Staffing levels and the skill mix of staff were sufficient to ensure that service users’ needs are met. Records of NVQ training are poor. Failure to carry out required checks on prospective employees means that service users are not being supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staffing levels were at those agreed with the previous regulatory authority and staff reported that staffing levels were adequate to meet the needs of service users. Service users said commented positively about care staff. It was evident from discussion and documentation that relevant staff training is provided and ongoing. New staff receive TOPSS based induction training and are supervised by experienced staff. However, the registered manager was unsure how many staff hold NVQ qualifications. A previous recommendation for an action plan to be produced to ensure that 50 of staff hold an NVQ qualification by 2005 has not been addressed. It was disappointing and of concern to note that staff are not being recruited in accordance with the home’s policy and procedure. An immediate requirements notice was issued to the registered manager on the day of the inspection as two members of staff had been employed without POVA (Protection of Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 18 Vulnerable Adults) and CRB (Criminal Record Bureau) checks being obtained. Also, references had not been obtained for one member of staff. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 38 The registered manager is not fully discharging his responsibilities. To ensure that the home is run in the best interest of service users, their views should be sought using the quality assurance process. Monitoring of food cooking and storage temperatures is inadequate and places service users at potential risk as does the communal use of soap and washing equipment. EVIDENCE: The registered manager, Mr Jeremy Martin, is also the registered provider. He has over seventeen years’ experience of working with this particular service user group. Mr Martin has not completed the NVQ level 4 in care and management and said that he was to speak to a training provider about this. Owing to shortfalls identified in other parts of this report, it is evident that Mr Martin is not running and managing the home to the standard required by the Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 20 regulations and national minimum standards for older people. Where, in the past, the Commission has considered enforcement action with regard to staff recruitment, standards have been raised, but the findings of this inspection demonstrate that recruitment standards are not being maintained and service users are being placed at potential risk. Mr Martin explained that he has regular contact with and feedback from service users, but that formal service user meetings are not held. As part of the home’s quality assurance process, questionnaires are given to service users’ relatives to complete but only a few have so far been returned. Staff meetings are held and staff reported that Mr Martin was approachable and supportive and that staff morale was alright at present. Work place risk assessments and policies and procedures are in place and kept under review. A sample of maintenance documentation was inspected and was satisfactory. Mr Martin has received fire safety competent person training. Fire safety tests are carried out as required and staff fire safety training is ongoing. It is positive to note that new staff have received this training. Accident records are maintained and cross-referenced with entries in the daily records with the exception of one accident, which had not been recorded in the accident log. The accident logbook must be kept up to date. Communal soaps and washing equipment were in evidence in bathrooms and the communal use of such items should be discontinued to promote good hygiene and prevent any risk of cross infection. Also, as noted above, some bath mats were soiled with faecal matter as was a toilet floor and a bedroom carpet was stained. An Environmental Health Officer inspected the kitchen premises on 13 April 2005. It was evident that some recommended work had been carried out. It was of concern to note, however, that food temperature checks had not been completed since 15.05.05 and that although staff working in the kitchen had received relevant training, they were not recording food, fridge and freezer temperatures because they said they had not been told to maintain temperature records. The inspectors informed the registered manager of this on the day, advising that appropriate action must be taken to ensure that food is cooked and stored at the correct temperature. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 21 Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 1 x 3 3 x 3 x 2 STAFFING Standard No Score 27 3 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 1 x 1 x x x 1 1 Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 23 Yes 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 3 Timescale for action 14(1)(d) Following assessment, the From the registered person must confirm next in writing to the service user that admission their health and welfare needs and can be met at the care home thereafter 15(2)(a)(c Service users or their 08.07.05 representative must be consulted about the service users plan 13(3) Accurate medication records 08.07.05 must be kept; stock must reconcile with records held; secondary dispensing of medication must stop. 13(6) All staff working at the home 08.09.05 must receive adult protection awareness training 23(4)(a) Fire doors must not be wedged 08.07.05 open. Appropriate hold open devices must be used which meet fire safety requirements 19(1)(b)(i Required checks must be carried 08.06.05 ) out on prospective employees before they start working at the care home. 9 The registered manager must 08.07.05 take action to address identified shortfalls; the care home must be managed and run to the required standard. 24 The registered person must 07.10.05 J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 24 Regulation Requirement 2. 7 3. 9 4. 5. 18 19 6. 29 7. 31 8. 33 Holme House 9. 10. 37 38 17(2) Schedule 4 13(3) 11. 38 13(3) consult with service users as part of the quality assurance process and supply to the Commission and make available to service users a report in respect of the quality review currently being carried out. The registered managers 08.07.05 working hours must be included on the staffing rota The findings of the 19.07.05 Environmental Health Officers report dated 18.04.05 must be fully actioned. The use of communal soap and 08.07.05 washing equipment must be discontinued; bath mats must be kept clean; toilet areas must be kept clean; staining must be removed from the identified bedroom carpet or the carpet replaced. 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. 4. 5. 6. 7. Refer to Standard 2 8 21 24 25 26 28 Good Practice Recommendations Each service user should have a written statement of terms and conditions with the home. A record of service users weight gain/loss should be maintained. The toilet flooring identified during previous inspections should be replaced The wall mounted cupboards in service users bedrooms should be resited or replaced to promote health and safety The registered manager should supply the Commission with a revised action plan for ensuring safe water temperatures and preventing risks from scalding. Readily cleanable/washable laundry containers should be provided to promote hygiene and reduce the risk of cross infection. The registered manager should provide the Commission with an action plan detailing how 50 of staff are to J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 25 Holme House 8. 31 achieve NVQ level 2 qualification or equivalent by 2005. The registered manager should obtain an NVQ level 4 in care and management or equivalent by 2005. Holme House J51J01_s26273_holme house_v231314_070605.doc Version 1.30 Page 26 Commission for Social Care Inspection Park View House Woodvale Office Park Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 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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