Inspection on 24/06/08 for Holmers House

This inspection was carried out on 24th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmers House 16/06/09

Holmers House 15/09/08

Holmers House 27/06/07

Holmers House 21/08/06

Holmers House 20/12/05

Holmers House 14/09/05

Holmers House 25/01/05

Holmers House 03/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Holmers House Holmers Farm Way Cressex Road High Wycombe Bucks HP12 4PU     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Date: 2     5 0 6 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 41 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 41 Information about the care home Name of care home: Address: Holmers House Holmers Farm Way Cressex Road High Wycombe Bucks HP12 4PU 01494 769560 01494 769566 alison.pulley@heritagecare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable): Type of registration: Number of places registered: Heritage Care Miss Alison Pulley care home 48 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 48. The registered person may provide the following category of service only:Care home personal care - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Physical disability (PD) Old age- not falling within any other category (OP) 0 0 0 Over 65 0 0 0 Date of last inspection Brief description of the care home Homers House is a purpose built residential home, registered to provide care for up to 48 elderly persons within the category of old age and dementia type illness. The home is owned and managed by Heritage Care. Accommodation is provided in Care Homes for Older People Page 4 of 41 single rooms. The home is divided into smaller units, each with its own sitting room, dining room and kitchenette. There are safe accessible gardens to the rear and side of the property and car parking to the front. The home is situated in a residential area of High Wycombe, which has all the amenities of a large market town and has good commuter links. Public transport is accessible to the area. There are leisure facilities nearby and there is a large national department store and national chain supermarket in the same area as the home. Service users are registered with general (GP) practitioner practices and all service users have access to local national health services through GP referrals. Community Nurses visit the home and provide support to the home as needed. Care Homes for Older People Page 5 of 41 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced inspection was carried out by two inspectors in June 2008. The inspection process included consideration of information provided by the registered manager and others in advance of the inspection, a visit to the home, examination of records (including care plans), discussion with staff, residents and visitors, discussion with the manager and deputy manager, a walk around the home and garden, observation of practice, and consideration of the results of a CSCI survey in which questionnaires were sent to residents, staff and health and social care professionals. This inspection also included a SOFI exercise. Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people in this inspection to help us understand. Care Homes for Older People Page 6 of 41 We call this the Short Observational Framework for Inspection (SOFI). This involved us observing up to 4 people who use services for 2 hours and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who use services, and the environment. Fees at the time of this inspection were £550 per week. What the care home does well: What has improved since the last inspection? What they could do better: The home must review its approach to care planning and improve standards. The use of documents making up care plans should be reviewed and the inclusion of those that do not support good quality care be reconsidered. This work should be supported by staff training and supervision and it is suggested that standards of practice be assessed through care plan audit. The home should consider whether the current level and range of activities is sufficient for the needs of residents. The process might be informed by seeking the views of a range of stakeholders (including residents, staff, relatives and professional staff who are in regular contact with the home). Standards of decor are variable and the Registered Manager must ensure there are Care Homes for Older People Page 8 of 41 effective systems in place to deal promptly with minor repairs and that there is an ongoing programme of redecoration and refurbishment. A number of staff matters need management attention. The Registered Persons are advised to carry out a review of staffing levels to ensure there are sufficient staff to meet the needs of residents. The staffing structure should be reviewed in the context of clarifying accountability for the quality of care and consideration of whether the present structure sufficiently meets that requirement. The opportunities which the current joint Heritage Care and Alzheimers Society staff training programme offers to improve standards of care need to be identified and incorporated into care practice. Staff supervision must be implemented more consistently and should facilitate skills development and improvements in the quality of the service. Managers and supervisors must ensure that aspects of staff practice which compromise the privacy and dignity of individual residents cease. The Registered Manager should explore ways of regularly engaging with relatives so that their views are taken account of. The proposal to hold a meeting with relatives, residents and a representative of the Alzheimers Society should be put into effect. An effective programme of quality assurance must be established by managers. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line – 0870 240 7535. Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 41 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People considering moving into the home can be assured that their needs will be assessed by experienced staff prior to admission. Evidence: Heritage Care have a block contract with Buckinghamshire County Council. All referrals to the home originate from the Councils Social Services department Central Resource Team. The referring care manager provides an initial summary of the prospective residents situation. Acceptance by the home at this point triggers the homes own assessment process. This involves an assessment of the person by an experienced member of staff, usually the registered manager or deputy manager. The assessment is structured by Heritage Care Homes for Older People Page 11 of 41 Cares assessment procedure. The process includes contact with the persons family, and consideration of supplementary information, such as that from NHS hospital or community care services, where required. The home also obtains a copy of relevant information from social services, such as the Client Assessment Report. The registered manager reported problems in obtaining adequate information on occasions from NHS hospital services, in particular in situations where there is pressure to discharge the person from hospital. Liaison with community based teams such as the Community Mental Health Team (CMHT) for Older People is reported to be good. Acceptance of a referral may lead to a visit to the home by the persons family prior to admission. In all cases an initial four to six week trial admission takes place. At the end of this period a review is held. If it is agreed that the person appears to be settling in well and the home can meet their needs then a permanent place is offered. Prior to visiting the home we received some concerns about its capacity to fully meet some residents needs. There were three aspects to these concerns. Firstly, questions about the capacity of the home to meet peoples needs in terms of the effective management of its resources. Secondly, in terms of the needs of residents exceeding the capacity of the home to meet those needs - some respondents, for example, felt that some residents needed nursing care which the home does not offer. Thirdly, in terms of staffing levels being sufficient to meet residents needs. With regard to the first of these, effective management of resources, elsewhere in this report we suggest there are a number of matters which require management attention if the quality of the service is to improve. With regard to the third, staffing levels, again elsewhere in this report, we refer to concerns communicated to us about staffing and suggest that these be reviewed with senior managers. This leaves the question of the assessment process potentially failing to identify people with a higher level of need than the home can meet. This is not supported by the findings of this inspection. Neither health nor social care professionals in contact with the home thought this to be the case. They did not feel that people referred to Holmers House were more dependant than those referred to similar homes elsewhere in Buckinghamshire, including others run by Heritage Care. Neither the registered manager nor the deputy manager though this to be the case. They felt that the homes assessment processes were thorough, that admissions to the home since the last inspection were appropriate, and that it was not admitting people whose needs it could not meet. Care Homes for Older People Page 12 of 41 Examination of the records of three people admitted since the last inspection showed that a systematic process of assessment was carried out prior to admission. The process included an assessment of needs by the home, appropriate communication with the referring care manager, and that relevant information had been obtained from NHS services. A further assessment of needs is carried out on admission and during the trial period. Examination of records on this inspection did not support the view that some people with nursing care needs were being admitted. This is not to say that peoples needs dont change over time. In such circumstances a home will need to review the persons needs and, jointly with other agencies where necessary, consider whether it can continue meet those needs within its resources. The home does not offer intermediate care therefore standard 6 does not apply. Care Homes for Older People Page 13 of 41 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Weaknesses in the implementation of the homes arrangements for care planning and delivery may lead to peoples needs not being fully met. Weaknesses in the administration of medicines on occasions increases the potential for errors to occur with consequent risk to residents. Evidence: A care plan is in place for each resident. Care plans are comprehensive. The structure of care plans include pre-admission assessment (which include a scoring system for some sections), assessment of needs, risk assessments, manual handling assessments, dietary preferences, weight log, Waterlow pressure assessment, missing person information, and a personal care plan. The organisations care plan includes one section headed Finance and Spiritual - an Care Homes for Older People Page 14 of 41 odd combination. We discussed the matter of nutrition assessment in the home. The manager said that the dietary preferences form acts as a first screen for a persons nutritional status. If problems are identified at that stage then a referral to a dietitian is considered. It was noted (in the records examined) that changes in weight are recorded without comment. While this inspection raises no significant concerns about the nutritional welfare of residents the manager may wish to consider further the homes approach to this matter. Guidance may be found on the CSCI Professional website. Care plans included a clothing inventory. It is difficult to see what this contributes to the care of the person some time after it has been completed. It was noted in one case that the clothing inventory was for a male while the resident to which it applied was female. The section on personal planning is typed and written in the first person sense. This is helpful providing it is firmly based on the persons wishes. Some of the care plans examined included handwritten amendments which had not been signed or dated. The basis for such amendments was not clear nor the authority of the person making them. One care plan included a life history but again the form was unsigned and undated by the person recording it. The section on physical care in the records examined was completed reasonably well. Some potentially significant information had been entered without comment. In one case a weight loss of 2.25Kg (just under 5.0 pounds) in one month was entered without comment even though there is space on the weight chart for this. In a number of bowel charts the time interval had been entered without comment e.g. four days, five days, twelve days, and fourteen days. One would expect some action to be taken in such circumstances. All residents are registered with a GP in a number of practices in High Wycombe. The manager said that the home has encountered problems in GPs accepting residents on occasions - although all are placed eventually. The home is in regular contact with staff from the Community Mental Health Team for Older People. No residents had pressure sores at the time of this inspection. District Nurses, physiotherapy, dietetics, and audiology are accessed via the residents GP. An optician visits the home on request. Dental services are mainly provided through the NHS at a local health centre. A chiropodist visits the home. Professional respondents to the CSCI survey carried out in connection with this inspection communicated dissatisfaction with some aspects of the home. One Care Homes for Older People Page 15 of 41 respondent felt that some healthcare needs were not being met despite matters being raised at multi-agency reviews. It was said that some details of care were not followed through by the home even though they had been agreed at review meetings. A failure to conform to a Heritage Care clinical policy had been the subject of discussion at a multi-agency meeting earlier in the year. Medicines are prescribed by the residents GP and are supplied through Boots Chemists - where possible in its monitored dosage system. We were told at the time of the inspection that no residents were assessed as being able to manage their own medication. There is a policy in place to enable this to happen if it is considered safe for the resident to do so. The medication administration record (MAR) sheets were examined and no unexplained gaps were noted. Some inconsistencies in staff practice were noted. For example, we noted that Ferrous Fumarate (a form of iron used in the treatment of anaemia) had been signed as having being given to a particular resident. The medication was still in the blister pack but the bubble had been perforated. It was evident that the staff member concerned did not notice the tablet was still in the blister pack. We also observed on another residents MAR sheet prescribed Ferrous Fumarate, that the tablet to be administered at lunchtime was still in the blister pack later in the afternoon. A scribbled over entry was recorded on the sheet. However, there was no written explanation recorded stating why the tablet had not been administered. We were made aware of other errors in medicines administration. The home had introduced protocols to minimise the risk of errors occurring. Two senior staff members are now required to sign for all medication received in the home. We noted on the MAR sheets for two residents that antibiotic treatment had been prescribed. This meant that staff had to transcribe handwritten entries on the MAR sheets. We noted that two staff members signatures were recorded on the sheets in conformance to good practice guidelines. However, the number of tablets and date the tablets were received had not been recorded on the MAR sheets. Staff should be reminded to record on the MAR sheets the date and number of tablets received to ensure consistency in practice. We observed a faxed memo in the medication folder from a general practitioner authorising staff to administer Promazine medication to a particular resident covertly. There was no written evidence or protocol in place to confirm that the residents relative or representative had been involved in this arrangement. Staff on the unit who were caring for the resident said that the person was able to take the medication without having to disguise it but this information was not clearly recorded in the persons care plan and had not been reviewed. The home should ensure that family members and other professionals are involved in decisions regarding covert Care Homes for Older People Page 16 of 41 medication and that the outcomes are clearly documented. The home may find it helpful to refer to guidance from the Royal Pharmaceutical Society of Great Britain (2007) and from CSCI (2008) on the administration of medicines and in particular covert administration. The controlled drug register was examined. We noted that the recording of medication stock received was not clear. This could potentially pose a risk. It is recommended that medication received is clearly recorded in the controlled drug register and that entries are checked by two members of staff to minimise the risk of errors and to ensure a clear audit trail of medication in the home. The controlled medication was checked and the stock balance corresponded with the records. The record for medication leaving the home was satisfactorily maintained and ensures safety. A recommendation had earlier been made that the home develop a protocol for the safe administration of Alendronic Acid and it is noted that this is now in place. Staff spoken to confirmed that they receive regular training on the administration of medicines and that their practice is observed by a senior staff member to ensure they are administering medication correctly, and in accordance with policy and good practice. We were told that personal care is provided in private in residents bedrooms. However, we observed one male residents dignity being compromised. His trousers fell off in the lounge on two occasions. He was not wearing a belt and staff did not take appropriate action to take him to his bedroom and provide him with a belt. In one residents bedroom there was a notice reminding staff to ensure that they put on her bra when dressing her. The way the information was displayed could be perceived as insensitive and not providing care in a dignified and person centred manner. A second note was observed on the notice board in the dining area (on Willow unit) informing staff that a particular resident attends a day centre on Mondays and Thursdays. We would expect a care home to have more appropriate ways of communicating such information. Care Homes for Older People Page 17 of 41 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have access to an activity programme which aims to maintain physical, social and intellectual skills. However, the range of activities may not meet the needs of all residents and those not involved are at risk of a decline in skills if this is not addressed. Evidence: The home has two activity organisers. One works ten hours a week and the second fifteen hours a week. Other entertainers come to the home on a monthly basis, and outings, bingo and shopping trips are organised for residents who can participate in these activities. We were told that an activity organiser escorts residents who wish to attend a weekly coffee morning in a local church hall on Thursdays. We were told that a local firm supports the home and their staff organise cream tea parties and provide musical entertainment for residents. The home also has three activity volunteers who arrange tabletop sales and other events. We observed handmade jewellery on display in the home for sale and these items were made by one of the volunteers. All funds Care Homes for Older People Page 18 of 41 raised go towards the comfort fund. It was said that during good weather residents enjoy sitting under the gazebo in the garden having tea. On the day of the inspection the trolley shop was available for residents to purchase confectionery. Residents on Willow unit were engaged in making a collage of the Royal family. The weekly activity programme was displayed on the unit There are no restrictions on visiting. Residents may see visitors in private in their own rooms if they wish to. Contact with family, friends and the local community is encouraged. We were told that residents are often invited to events such as tea tasting, variety shows and quizzes at a local college. We spoke to a visitor who was visiting. He was happy with the care provided to his relative and said that staff always made him feel welcome and offered him refreshments. Another visitor spoken to during the visit also expressed satisfaction with this aspect of life in the home. Church services are held in the home on three Sundays a month to ensure that residents who wish to practice their religious beliefs are supported in doing so. A health or social care professional respondent to the CSCI survey expressed concern at what was felt was a limited range of activities for residents. Records of residents participation in activities in individual care plans were very limited. In one case six activities of limited duration were recorded for an entire month. In another care plan, five activities were recorded between December 2007 and June 2008. It is felt that some interactions noted during the SOFI exercise between staff and residents in the lounge might have been better handled to promote the dignity and privacy of residents. We observed the following:· A member of staff could be heard by all occupants of the lounge asking a resident how many sweeteners they would like in their tea. · A member of staff asked residents if they wished for the television to be on after lunch. There was no response from residents and the staff member chose to turn on the television. · A resident paid a staff member a compliment on the lovely cup of tea she had made but the staff member did not acknowledge the compliment or further engage the person in conversation. · A member of staff was observed talking over residents rather than to them. For example, two residents were spoken to at a distance by a staff member who wanted to know if they wished to have a hot or a cold drink. · Staff were observed addressing residents as dears and darlings. Care Homes for Older People Page 19 of 41 It is hoped that these matters will be addressed through the staff training programme and through supervision by team leaders and managers. The home provides residents with three meals a day and hot and cold drinks and snacks are available at all times and offered regularly. We noticed that the menu for the week was displayed in the dining area so that residents would be aware what was on offer. The document has a different colour for each day – an innovative practice. The format might be further enhanced by using a larger print to ensure that all residents are able to read it, especially those with impaired vision. For residents eating in the dining room tables had been laid creating a pleasant and homely atmosphere with the provision of napkins and clothes protectors. Some residents were assisted by staff in cutting their food to promote independence. Lunch was served in a relaxed manner. There were two meal choices on offer on the menu but only one choice was provided. The meal served was roast turkey, roast stuffing and mashed potatoes. The second choice of sausages and onion gravy was not available. The menu stated that spotted dick and custard was on offer for dessert but residents were provided with fruit and ice cream instead. All however, seemed satisfied with this. The home was caring for an Afro Caribbean person. However, there was no evidence seen to confirm that his particular dietary needs were being adequately met. Staff were of the impression that his wife brought him Caribbean food when she visited. The manager said this was not the case. The home should ensure that arrangements are in place for his specific food preferences to be met. Copies of the lunch and supper menus were provided for this inspection. Care Homes for Older People Page 20 of 41 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents interests are protected by the homes policies, procedures and staff training on abuse, complaints and managing residents monies. However, weaknesses in other areas of care may expose residents to risk. Evidence: There is a policy governing the management of complaints. A copy of the complaints procedure is on display in the foyer and there is a reference to the procedure in the homes statement of purpose and service users guide. The complaints and compliments record was examined. 11 complaints and 4 compliments have been recorded since January 2008. The record includes an action note for each complaint. CSCI has received two complaints about the home since the last inspection. There are policies governing safeguarding vulnerable adults (last reviewed in March 2008) and whistle blowing. These are readily accessible to staff in the office or on line through the organisations intranet. A copy of the current Buckinghamshire joint agency safeguarding procedure was available in the office. The subject of Care Homes for Older People Page 21 of 41 safeguarding - also know as protection of vulnerable adults (POVA) - is included in the induction programme for new staff and in the ongoing programme of staff training and development. Staff have attended training events run by Heritage Care and Buckinghamshire County Council. There have been two safeguarding investigations since the last inspection. The home communicates appropriately with statutory services in such circumstances. However, weaknesses in care planning and delivery, identified elsewhere in this report could compromise the quality of care for residents and potentially expose residents to risk. Staff have attended training on the Mental Capacity Act 2005 and the manager is an internal trainer on the subject. Information on IMCAs (Independent Mental Capacity Advocates) was on display in the foyer. The training programme on the subject of dementia includes training on responding to challenging behaviour (including verbal and physical aggression). Policies and procedures are in place for managing residents monies. The home does not act as an appointee for residents. This role is normally carried out by a close relative of the person or by Buckinghamshire County Council. These are managed on a day to day basis by administrative staff. They are summarised elsewhere in this report. Care Homes for Older People Page 22 of 41 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home generally provides a pleasant and safe environment for residents. Greater attention to the detail of the environment and a programme of redecoration or refurbishment however, would provide residents with a more comfortable home in which to live. Evidence: The home is located in a residential area on the outskirts of High Wycombe, about two miles from the town centre. The area is served by buses to and from High Wycombe. The nearest rail station is High Wycombe. There is parking to the front and side of the building. Entry is controlled by staff. The building is around five years old and is divided into three care units: Mimosa, Juniper and Willow. The ground floor comprises administrative offices, staff accommodation, kitchen, and two of the care units. There is a pleasant enclosed garden to the rear of the building. Each care unit is comprised of sixteen places and has its own kitchenette, dining room and lounge area. There is a bathroom and two WCs on each unit. These are fitted with grab rails and other aids to promote independence. Entry and exit to each of the care units is controlled by an electronic Care Homes for Older People Page 23 of 41 lock. Access to the first floor is through stairs or passenger lift. The first floor comprises the laundry and one of the care units. The overall quality of the environment is variable. New flooring has been laid in some areas. In other areas there are clear signs of wear and tear. Paintwork on walls and skirting boards in corridors and lounges was chipped and required repainting. In particular it is felt that the following matters require attention. Willows Unit Cracked wall tiles in kitchen area need replacing Toilet holders need replacing There was a strong odour in one bedroom. Mimosa Unit Noticeable odour in this unit. The manager said that the floor covering in the corridor was due to be replaced. A kitchen drawer was broken and needed to be replaced. A handle on drawer of kitchen cupboard needed to be replaced. Bottles of tomato sauce which had been opened were not refrigerated. The bottles were not labelled to indicate date of opening. These are perishable products and should be refrigerated once opened, labelled with date of opening and should not be used beyond the date specified on the label (usually four to six weeks). Juniper Unit A kitchen cupboard door was broken and needed attention Opened packets of biscuits were not stored in an airtight container to retain their freshness. There was an open tin of peaches in a refrigerator without a date label. Canned food, once opened, must not be stored in the tin. It must be stored in a suitable container and labelled with the date of opening. All perishable foods must be labelled when opened. A cover on a waste bin was broken and needed to be replaced Laundry Room Improvements were noted in the laundry room. It was evident that the cleaning schedule was being adhered to. The room was clean and tidy. Care Homes for Older People Page 24 of 41 Main Kitchen Gaps were noted on food temperature records in the main kitchen. A cupboard with COSHH solutions was not locked. Staff Attire Staff were not wearing name badges. This may be a matter of policy but name badges may assist residents with memory impairment to remember staff names. There did not appear to be a dress code and it was noted that some staff wore open toe sandals, which, apart from their appropriateness for this form of work could potentially pose a risk to their safety. Others were noted to wear shorts and casual clothing which it is felt may not be appropriate for a care setting. Care Homes for Older People Page 25 of 41 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be assured that, in general, there are sufficient numbers of staff to meet their needs. However, there may be occasions where, either the numbers of staff on duty are insufficient, or there are insufficient numbers of staff with the right experience and skills to meet peoples needs. Evidence: The present staff establishment provides for three care staff on each unit in the morning, three each afternoon and evening and one member of staff on each unit at night. In addition there is a team leader who acts as duty officer for the home. These numbers do not include the manager and deputy manager. Other staff include housekeepers and laundry assistants (264 hours in total per week), administrative staff (two, part-time, 38 hours in total), activity organisers (two, parttime, 25 hours in total), kitchen staff (chef, assistant cook and kitchen assistant) and maintenance staff (a handyman for Heritage care homes in Buckinghamshire and where necessary others on contract to English Churches Housing). A number of respondents to the CSCI survey carried out in connection with this Care Homes for Older People Page 26 of 41 inspection commented on staffing in the home. Responses were mixed. Many respondents acknowledged the good work carried out by staff. However, a number felt that staff were working under pressure at times and attributed this to staff shortages and high turnover of staff. One wrote There are one or two very good staff members. I have noticed there is a lot of unhappiness among staff. Other respondents reported a lack of communication between some younger staff and residents on occasions. One wrote Basic communication skills can be a problem…some carers rush things on occasion and do not check if individual (resident) understands. Some staff were reported to be curt in their communication with residents at times. Communications were considered to be centred more on tasks than on people - an observation which was also noted during the SOFI exercise carried out on this inspection. Respondents noted communication problems and tensions between staff on occasions. Comments were also made on an apparent lack of a dress code in the home - a matter which may have health and safety as well as aesthetic considerations. These responses were discussed with the manager. The responses communicated an impression of a home where standards in this area are uneven - too uneven to be left alone. They touch on a range of matters including staff numbers, staff skills, staff organisation, staff support and supervision, communication at different levels, relationships with visitors, and other aspects of the homes processes and culture, each of which has a bearing on the quality of care provided to residents. The home is supported in the recruitment of new staff by the organisations head office in Loughton, Essex. The home advertises locally in the High Wycombe area. Applicants are required to complete an application form, provide two references, complete a health form, provide CRB certificates, and evidence of a POVA first check if employed before a CRB certificate is received. Five personnel files were examined during the inspection visit. All had completed an application form. In one out of five files no references were on file at the time of the inspection visit, in two of five files evidence of fitness for the post was not on file, all five had a recent photograph of the person, in four out of five files the CRB level, number and date had been hand written by the manager. While we have no reason to question the integrity of this practice it is preferable, where the CRB certificate is held centrally, if a member of staff with appropriate delegated authority who has had sight of the original certificate, communicates this information in the form of a typed report to the registered manager. Newly appointed staff undertake a 12 week induction programme which the manager said conforms to the Skills for Care foundation standards. This can be extended if Care Homes for Older People Page 27 of 41 necessary. The manager said that at the time of this inspection 58 of staff had acquired an NVQ at level 2 or above. Staff benefit from a comprehensive training programme organised by Heritage Care. Details in the form of a spreadsheet were provided for the inspection. Subjects include (among others); Manual Handling, Fire Safety, Medication, Emergency Aid, Food Hygiene, Personal Care and Infection Control, Health & Safety, Infection Control (Team Leaders), Mental Capacity Act, Responding to a CSCI report and Tissue Viability. A new programme of dementia training was getting under way in 2008. This was being run in conjunction with the Alzheimers Society. Training on the administration of medicines is based on the Boots Chemists programme with staff undertaking an Observation Test and a Written Test. Care Homes for Older People Page 28 of 41 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards of management and supervisory practice are uneven and on occasions may expose residents to risk. Weaknesses noted in this report need to be effectively addressed in order to reduce that risk. Evidence: The manager has been in post since December 2006 and prior to that time was deputy manager. The manager has considerable experience in the residential care sector and has acquired the Registered Managers Award (RMA). The manager said she keeps up to date with developments in the field through attending short courses, reading care journals, and material published on specific subjects on the internet. Care Homes for Older People Page 29 of 41 The manager is accountable to the area manager and has a deputy manager accountable to her. The deputy manager was on maternity leave at the time of this inspection and an acting deputy manager had been transferred from another Heritage Care Home for a limited period of time. Each of the three care units is managed by two care team leaders. The manager is also responsible for an adjacent 12 place supported housing scheme. This inspection identifies a number of matters which require management attention. Responsibility for addressing these lies with the registered persons - the registered manager and the responsible individual. The potential impact of managerial style, staff turnover, staff skills, and managerial and staffing structures were discussed with the manager during the course of this inspection. These are matters for the organisation, but the question of accountability for the quality of care in each of the three care units below the level of the deputy manager may merit review with senior managers. The manager said that a Care Audit had been carried out by the manager of another Heritage Care home in the autumn. A copy of the report of that audit was not available at the time of the visit. The manager did provide a copy of the organisations Care Pathways audit 2007 - Older People Services. According to the report this looked at two standards (Heritage Care standards): Keeping well - healthcare and Keeping well - medication. The report provided for this inspection was not specific to Holmers House and it is difficult therefore to draw specific conclusions from it. It is noted that section 4 (Data Analysis and Reporting) states Findings for each scheme were collated and a House Audit document produced for each scheme. That document was not readily accessible at the time of this inspection. The home did not hold regular meetings with residents and relatives. The activity coordinator organises regular feedback sessions with residents. The manager has been in contact with the Alzheimers Society who have offered to participate in meetings with relatives. A date for a first meeting had yet to be agreed. Informal feedback from relatives is obtained at informal gatherings such as summer barbeques, the Christmas bazaar and the Christmas party. The content of responses on the quality of the service in the CSCI survey varied. A summary of the main themes was given to the manager. There were positive comments such as those of a relative who said that the staff at Holmers House Understand and cares for the people they look after, and another who wrote that the home Provides a caring environment for my [relationship of resident to respondent]. A visiting relative seen during the inspection expressed a high level of satisfaction with care in the home although there had been two significant failures in the administration Care Homes for Older People Page 30 of 41 of medicines to her relative over the past year. As noted elsewhere in this report other relatives also expressed satisfaction with the home. Such positive comments were outweighed on this occasion however, by those expressing concerns about the quality of the service. These included concerns about the detail of care including standards of residents rooming, one relative finding a resident wearing anothers clothes, a reported lack of interaction between younger staff and residents, the quality of interaction between staff and residents on occasions, and an apparent lack of resident choice. Feedback from health and social care professional staff expressed concerns about levels of stimulation and activity for residents, in some instances about the quality of personal care in terms of staff responses to residents needs, communication between staff and residents (e.g. curt responses and not allowing enough time to check if residents understand instructions), and a failure to continue care as agreed at multiagency meetings. Responses included comments on apparent poor working relationships between staff at times. Respondents acknowledged there were good staff working in the home, but that on occasions the atmosphere did not facilitate the provision of good quality care to residents. Respondents indicated a need for a greater level of staff knowledge and skills on the care of people with dementia. Comments from staff respondents were also mixed. Staff acknowledged the opportunities for training and development within the home and in working for Heritage Care e.g. Training is excellent and very thorough. A number felt that staffing levels were inadequate. Some felt that the level of dependency of some residents was high and more suited to the skills, staffing levels and facilities of a nursing home - although a member of staff who had worked in a Heritage Care home elsewhere did not share this view. Responses also included reference to tension between staff on occasions and high staff turnover. Heritage Cares own management systems should enable it to make its own assessment of Holmers House and its performance in relation to similar homes elsewhere. On the basis of responses to this inspection however, there does appear to be a need for managers to explore these issues with staff and other stakeholders and to resolve them where possible. The arrangements for the management of residents finances are subject to the financial policies and procedures of Heritage Care. In the home these are overseen by administrative staff. Major financial transaction such as collection of fees are managed Care Homes for Older People Page 31 of 41 from the organisations Head Office in Loughton, Essex. The organisation does not act as appointee for any resident. The home has facilities for safe storage of cash and valuables. Systems are in place for recording all transactions and receipts are retained. Access to funds is available when the manager and administrator are on duty. Arrangements exist for the unit co-ordinators to access small amount of cash out of hours. The position with regard to staff supervision seemed unclear. The home is subject to the organisation’s policy Staff Support & Supervision (dated April 2006 and for review in April 2008). The policy does not define supervision but it is implied throughout that this is a formal, essentially one-to-one, process. The manager said that at present supervision is taking place every two months. It is mainly group supervision, not individual. It was unclear how group supervision differed from team meetings. All staff have an annual appraisal. The homes business plan for 2008-2009 aims to ensure that 50 of Bank staff receive documented supervision to a minimum of 6 times a year. This raises the question as to why only half of such staff are to have supervision to the minimum standard. Arrangements for Health & Safety are generally satisfactory. The home is subject to the organisations Health and Safety policy which was reviewed in 2006 (and is again due for review this year). Arrangements are in place for staff training at induction, basic and update levels. Subjects include Moving & Handling, Food Safety, Infection Control, First Aid, medicines administration, and safeguarding vulnerable adults. Elsewhere in this report we have noted our observations on perishable food items being opened but not refrigerated or labelled, to canned food being stored in its tin after opening, and to biscuits not being stored in an airtight container. In relation to fire safety, fire drills were carried out for night staff in February, April and June 2008, and for day staff in January and April 2008. This frequency is satisfactory but it was difficult to see whether the present system of records will ensure that all staff are included. According to records fire points were recently checked in April, May and June 2008 with variable intervals between checks. A fire risk assessment was carried out in April 2008. The fire officer visited the home in April 2007 and the registered manager said that all the recommendations of that visit have been implemented. Other aspects of health & safety including contracts for the maintenance of fire safety equipment, portable electrical appliance testing, gas appliance safety, and electrical wiring appear satisfactory. Risk assessments covering a range of matters are in place but had not been updated for 2008. It is recommended that the term Cot Sides be replaced with the term Bed Rails. Care Homes for Older People Page 32 of 41 The home was visited by a Health and Safety officer from Wycombe Council in October 2007 and by an Environmental Health Officer in August 2007. Care Homes for Older People Page 33 of 41 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 3 14 All sections of the preadmission form must be completed in full to ensure that important information about people using the service is not overlooked. 30/11/2007 2 7 15 People using the service care 30/11/2007 plans must be reviewed at least once a month to ensure that any changes in their care needs are reflected. 3 8 12(1) Nutritional and tissue viability assessments must be undertaken on admission and subsequently on a periodic basis to ensure that people using the service nutritional and skin integrity are regularly monitored. 30/11/2007 4 12 16(20(m) Details of people who use the 30/11/2007 service particular interests, hobbies and pastimes must be recorded in care plans to ensure that activities provided are appropriate to their needs and that they have the opportunity to pursue leisure interests. Care Homes for Older People Page 34 of 41 5 26 16 It is a requirement that the 30/11/2007 manager must address the issues regarding the unpleasant odours within some areas of the home. If deemed appropriate to eradicate such odours carpeting and other flooring must be replaced. A suitable cleaning regime must be carried out in all areas of the home to ensure cleanliness throughout (previous timescale of 31/3/06 not met). 6 29 Schedule 2 A recent photograph must be 30/11/2007 on all staff?s files to confirm proof of identification and to comply with current regulations 7 30 18 All staff must undertake dementia training to ensure that they are trained and skilled to meet the needs of people with dementia who use the service 30/11/2007 Care Homes for Older People Page 35 of 41 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 The Registered Manager must ensure that significant changes in residents health and welfare are fully recorded and acted on. To ensure that changes in residents health and welfare (such as weight loss) are properly investigated and acted on. 31/08/2008 2 7 15 The Registered Manager must ensure that care plans are accurately drawn up, effectively implemented and reviewed in order to meet residents needs. To ensure that care plans are based on an accurate assessment of the persons needs and support action to meet those needs. 31/08/2008 3 8 13 The Registered Manager 31/08/2008 must ensure that actions agreed at multi-agency meetings are acted on in the Care Homes for Older People Page 36 of 41 interests of residents health and welfare. To ensure that residents healthcare needs are met. 4 9 13 The Registered Manager must ensure that staff administering medicines do so in accordance with the prescription and the organisations policy and procedures To minimise the chances of errors in the administration of medicines to residents. 5 10 10 The Registered Manager 31/08/2008 must ensure that the privacy and dignity of residents is respected at all times. To protect the privacy and dignity of residents. 6 12 16 The Registered Manager must review the programme of activities to ensure that it is appropriate to the needs of residents. So that a suitable range of activities is provided which meets residents needs. The manager should consult with other stakeholders in the home as necessary. 7 19 16 The Registered Manager 31/10/2008 must take appropriate action to ensure that the untoward odours noted in some parts of the home are eliminated. 30/09/2008 31/08/2008 Care Homes for Older People Page 37 of 41 To provide a safe and pleasant environment for residents, staff and visitors. 8 27 18 The Registered Manager is 30/09/2008 required to carry out a thorough review of staffing levels and staff skills using an appropriate and reliable methodology. A report of the exercise should be retained for future inspection. To ensure that there are sufficient numbers of appropriately trained and experienced staff to meet the needs of people living in the home. 9 33 24 The Registered Manager is required to establish systems for reviewing the quality of care at regular intervals. A report of each review and of any corrective action taken shoukld be retained for inspection. To ensure that the care provided to residents fully meets their needs and that its quality is monitored by the Registered Persons. 10 38 38 The Registered Manager is 31/07/2008 required to ensure that all staff conform to good practice when handling food. To protect the health and welfare of residents and ensure that they are provided with food which 31/08/2008 Care Homes for Older People Page 38 of 41 has been stored in appropriate conditions. 11 38 23 The Registered Manager is 04/08/2008 required to ensure that the homes arrangements for fire safety are systematically implemented and adequate records maintained. To ensure the safety of residents, staff and visitors. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 5 7 It is recommended that the Registered Manager ensure that all relevant documents and amendments to care plans are signed and dated by authorised staff. It is recommended that the Registered Manager establish a system of periodic audit of care plans aimed at ensuring that standards of care planning practice within the home support action to meet residents needs. It is recommended that the Registered Manager review the implementation of the organisations policy and procedure with regard to the covert administration of medicines to ensure that practice in the home conforms strictly to policy and current best practice, and that it operates in the interests of residents. It is recommended that the Registered Manager review the implementation of arrangements for recording supplies of medicines received in the home so that an accurate record of medicines is maintained. It is recommended that residents participation in activities is recorded in care plans. It is recommended that the home provide a choice of meals to residents in accordance with the published menu. It is recommended that meals provided to residents take account of their individual needs, in particular those relating to dietery preference or religious or cultural requirements. It is recommended that the Registered Manager, in liaison 6 7 7 9 8 9 9 10 11 12 15 15 12 19 Care Homes for Older People Page 39 of 41 with senior managers in Heritage Care and relevant managers in the housing association, establish a programme of redecoration of the home. 13 19 It is recommended that the Registered Manager make arragements for the minor repairs outlined in this report to be addressed by Heritage Care, liaisng with the housing association responsible for the home as required. It is recommended that the Registered Manager obtain a typed and signed report from a person with appropriate delegated authority, recording the essential information from the CRB certificates of staff appointed, and fully meets the requirements of Schedule 2. It is recommended that the Registered Manager ensure that an ongoing programme of training for care staff on Dementia is maintained. It is recommended that the Registered Manager, in liaison with senior managers as required, review the management arrangements within the home to ensure that there are clear lines of accountability for the quality of care provided to residents. It is recommended that the Registered Manager establish means of regularly meeting with residents, relatives and other stakeholders. The nature of such meetings should be appropriate to the needs and wishes of those involved but summary notes should be retained for inspection. It is recommended that the Registered Manager establish a system of regular formal supervision of staff. 14 29 15 30 16 31 17 33 18 36 Care Homes for Older People Page 40 of 41 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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