Inspection on 14/12/05 for Holme Lea

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holme Lea 08/11/07

Holme Lea 27/02/07

Holme Lea 06/07/05

Holme Lea 06/03/05

Holme Lea 05/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Holme Lea Astley Road Stalybridge Tameside SK15 1RA Lead Inspector Steve Chick Unannounced Inspection 14th December 2005 11:00 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 Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holme Lea Address Astley Road Stalybridge Tameside SK15 1RA 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) 0161 338 5187 0161 304 0990 Tameside Care Limited Miss Elaine Bradley Care Home 48 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (18), Physical disability (1), Physical disability over 65 years of age (3), Sensory Impairment over 65 years of age (13) Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 18 OP up to 18 DE (E) up to 3 PD (E) up to 13 SI (E) and up to 5 MD (E) and 1 named individual PD. 6th July 2005 Date of last inspection Brief Description of the Service: Holme Lea is a large, two storey building in its own grounds, with ample car parking. It offers accommodation to up to 48 older people in single bedrooms. The home is situated in a residential area of Stalybridge, opposite Stamford Park, and is close to a main road offering public transport links to Stalybridge and Ashton Under Lyne. Communal space consists of five lounges, three dining rooms and a patio area to the rear of the building. The home is run by Tameside Care Limited, a not for profit organisation which operates several other care homes in Tameside. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection three service users were interviewed in private, as were two relatives of service users and two members of staff. Additionally discussions took place with the manager and a group of service users. The inspector also undertook a tour of the building and scrutinised a selection of service user and staff records as well as other documentation, including staff rotas. This inspection was unannounced and not all the standards were assessed. It is recommended that this report is read in conjunction with the previous report of the inspection in July 2005. What the service does well: What has improved since the last inspection? The procedure for vetting new staff was more rigorously undertaken. More activities were provided and the system for publicising them to service users had improved. Improvements to the provision of food identified at the last inspection had been maintained. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 6 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. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: None of these standards were assessed at this inspection. Holme Lea does not offer intermediate care. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 9 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 and 10. The written care planning process is not maintained with sufficient consistency or rigour. Internal communication systems are not always effective. Service users are treated with respect and dignity. EVIDENCE: A selection of service users’ files was scrutinised. All had a written plan of care. The plans of care and written risk assessments were varied in their quality. Examples were seen where there was conflicting information between a service user’s care plan and risk assessment or the assessment and the care plan. There was documentary evidence of care plans being updated. These amendments were not always dated. In one file seen there was no documentary evidence that the care plan had been reviewed in the previous four months. As with other documentation, the daily records varied in effectiveness. Not all noted whether or not issues identified in the care plan had been addressed. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 10 The proper maintenance of these records are a significant aspect of Holme Lea being able to ensure accountability and demonstrate that care is being appropriately offered. Similarly they are important to ensure staff have a clear and accurate reference for each service user’s current needs. Staff who were interviewed identified other means of communication within the home which meant they were not reliant on the written care plans and risk assessments. ‘Communication books’ and verbal handovers were identified as means of helping staff to keep up to date about a service user’s changing needs. Staff who were interviewed understood the internal communications systems although there was not always sufficient time to read the written communications. Relatives spoken to during the inspection, identified failures in the home’s internal communication as an area of frustration. There was insufficient evidence to establish if these communication failures were as a result of information not being recorded, or not being read. One relative did acknowledge that, whilst still not perfect, communication appeared to have improved more recently. Service users and relatives spoken to during the inspection were positive about the attitude of the carers in their delivery of care. Service users’ comments included - “[the staff are] sociable”, “staff use their manners” “[the home is] friendly” “very nice staff … no grumbles”. Service users reported that they were treated with respect by the staff. All service users had single rooms, which they could lock if they wished. Observation and discussion confirmed that service users were free to access their own rooms and any of the communal areas as they wished. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. Holme Lea offers an appropriate range of social activities within the home. Appropriate meals are provided offering some choice and ample portions. EVIDENCE: A rolling program of a range of activities was provided. This was planned and publicised on a monthly basis. The record of the residents’ meeting in November 2005 indicated that service users were happy with the activities on offer within the home. It was reported that a dedicated ‘activities coordinator’ came to the home twice a week. Local Churches visited the home on a regular basis. Service users spoken to during the inspection expressed satisfaction with the activities available within the home. During the inspection a light lunch was available as the home was holding its Christmas Party in the evening. The lunch was pleasantly presented. Documentary evidence was available to indicate that the menu was discussed at service user meetings and amended at the request of service users. Discussion with service users indicated that the improvement in the food identified at the last inspection had been maintained. One service user Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 12 mentioned that night staff had made her tea and toast at 01:00 on the morning of the inspection, as she could not sleep. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. Service users or their representatives are able to complain and complaints are dealt with appropriately. Service users are protected from abuse and exploitation. EVIDENCE: The home has an appropriate complaints procedure which is made available to service users and relatives. This documentation has been seen on previous inspections and was not scrutinised on this occasion. All service users and relatives who were asked, expressed the view that they could make a complaint and that it would be responded to appropriately. One relative cited how easy staff were to talk to as one of the best things about the home. Staff who were interviewed, believed that complaints from service users were appropriately responded to. Staff who were interviewed also demonstrated an understanding of the need to be aware of the possibility of abuse and poor practice within the home. Whilst being confident that that would not happen, they were aware of their responsibility to initiate action if they identified poor practice. All service users spoken to during the inspection were very clear that they felt safe at Holme Lea. They also reported that from their observations, other service users were also safe in the home. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 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 the following standard(s): 19, 21, 22, 23 and 24. The home has procedures in place to identify any maintenance requirements of the building and rectify them. Appropriate bathing and toilet facilities are provided. Service users’ own rooms are safe, comfortable, clean and personalised. The home provides appropriate aids for service users with restricted mobility. EVIDENCE: During the inspection a tour of the building was undertaken. The home presented as predominantly well maintained, with only one issue identified which required remedial action. This related to a dip in the floor of the upstairs lounge, which could present a tripping hazard. This had been identified by the manager and referred for action. She reported this work was to be undertaken in January 2006. A random selection of service users’ bedrooms was undertaken. All service users have single bedrooms and those seen presented as clean and tidy. There Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 15 was ample evidence of service users being able to personalise their own rooms. Appropriate aids to assist service users with restricted mobility were available. The manager reported that the home was able to access other more specialised aids, if necessary, for individual service users. The provision of a “rotary stand” for one service user was given as an example of this. Appropriate bathing and toilet facilities were available for service users. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 16 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 and 29. Staffing levels are maintained at an appropriate level. Staff are appropriately vetted and receive appropriate training EVIDENCE: The staff rota for the week beginning 5th December 2005 was scrutinised. This demonstrated that between three and six care staff were on duty between 07:00 and 08:00. In six out of the seven days a minimum of six care staff were on duty during the day (08:00 – 20:00). On the remaining day, only five care staff were available between 08:00 and 14:00. On five days during that week, seven care staff were on duty in the afternoon and early evening. These figures include the senior on duty but exclude the manager. The manager reported that she is available to assist with care duties if necessary. Three care staff were available between 20:00 – 07:00. Additionally the home has dedicated Kitchen and domestic staff and a ‘handyman’. The manager reported an improvement in the available staff hours since the last inspection. Service users and relatives who were spoken to during the inspection were positive about the staff team’s attitude and approach. There was less consistency in connection with the numbers of staff on duty. One service user reported that there were “ample” staff on duty while others experienced Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 17 staffing levels as sometimes problematic, particularly at night and at weekends. The manager reported that, of the 24 care staff, twelve held NVQ II and three held NVQ III. This represents 63 of the care staff holding an NVQ II or higher. A random selection of certificates were seen to verify this information. It was also reported by the manager that a further eight staff were either undertaking NVQ II, or were registered to start the course. The manager also reported that the organisation was maintaining its commitment to training staff on a range of relevant courses. This commitment to training was confirmed by staff who were interviewed. The manager reported that only one new member of staff had been employed at Holme Lea since the previous inspection in July 2005. Documentary evidence indicated that all the appropriate vetting procedures had been undertaken before they commenced work. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 18 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): 32 and 33. The management team at the home is open and approachable. Quality Audit systems are in place, but require some additional work. EVIDENCE: All service users spoken to during the inspection expressed the view that they could talk to both staff and management, who were friendly, open and approachable. This was confirmed by staff who reported an open, approachable and supportive management team. Relatives also reported positively about the ease with which the manager could be approached, with one relative describing her as “very helpful”. Issues in connection with the effectiveness of internal communication are addressed in the Health and Personal Care section above. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 19 The home produces a monthly newsletter and holds regular meetings for service users to air their views. Tameside Care Group undertakes a range of Quality Monitoring and Quality Audit procedures. These include periodically seeking the views of service users and relatives by the use of postal questionnaires which can be completed anonymously. An analysis of these questionnaires is available at the home and is provided to the Commission for Social Care Inspection. However, the analysis does not include information on how the organisation intends to address issues for possible improvement which are identified through this process. Cards asking for feedback / comments were available at the home which could be returned to the organisation via a ‘free post’ address . The manager reported that she was unaware of the effectiveness of this tool and had had no feedback passed back to her as a consequence of any comment made via this route. In respect of the last Quality Audit the manager was able to demonstrate that the issue relating to activities, identified through the audit, had been addressed at a service users meeting. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 3 3 X X STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X X X X X Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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 The registered person must ensure that all care plans are accurate, reviewed, updated and in sufficient detail to inform staff of the way in which identified needs must be met. The registered person must ensure that any report on the quality of care also addresses any means of improving the quality. Timescale for action 01/03/06 2 OP33 24 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered person must ensure that internal communication systems are monitored and reviewed so that all staff have the information they need to be aware of service users’ changing circumstances. The registered person should ensure that an action plan addressing how issues identified in any Quality Monitoring DS0000005571.V271327.R01.S.doc Version 5.0 Page 22 2 OP33 Holme Lea exercise, is included in the report before the report is made available to service users or the Commission for Social Care Inspection. Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. Extracts may not be used or reproduced without the express permission of CSCI Holme Lea DS0000005571.V271327.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!