CARE HOMES FOR OLDER PEOPLE
Holmlea Care Home Waverley Street Tibshelf Derbyshire DE55 5PS Lead Inspector
Rose Veale Unannounced Inspection 24th October 2005 10:30a 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 Holmlea Care Home DS0000035767.V260492.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. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Holmlea Care Home Address Waverley Street Tibshelf Derbyshire DE55 5PS 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) 01629 580000 Derbyshire County Council Dianne Bassett Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: Holmlea is situated near to the centre of the village of Tibshelf and is next to the local medical centre and pharmacy. The home provides 24 hour personal care and accommodation for 40 older people. The home is a purpose built, single storey building and all residents have single rooms. The design of the home is four separate wings with one wing being used primarily for short term care. The home has pleasant garden and patio areas fully accessible to residents. The home is owned by Derbyshire County Council. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4½ hours on one day. There were 37 residents accommodated in the home on the day of the inspection, including 3 residents for short term care and 2 for assessment. There was also one person for day care. Residents and staff were spoken with during the inspection. The care records of 4 residents were examined, plus other records related to the staffing and management of the home. The requirements made in the previous report were followed up with the manager. What the service does well: What has improved since the last inspection? What they could do better:
The complaints book at the home could be better used to record any complaints made, whether or not the complainant wants to make a formal complaint. The book should detail the action taken and the outcome of the
Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 6 complaint. This would ensure that residents’ concerns and complaints were taken seriously and properly recorded. The bathroom on green wing remains out of use, despite requirements from previous inspections that this bathroom must be put back into use. This limits residents’ choice Staff records held at the home did not all have copies of the Criminal Record Bureau, (CRB), disclosures as required. The manager said this was being addressed as some copies had been received. There was a smell of cigarette smoke in the main entrance area and the main office from the staff room opposite the office. The manager said that staff would not be allowed to smoke in the building from 1st November 2005. This would improve the atmosphere for residents, staff and visitors. 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. Holmlea Care Home DS0000035767.V260492.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 Holmlea Care Home DS0000035767.V260492.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: These standards were not assessed at this inspection. Of the key standards, Standard 3 was assessed and met at the last inspection and Standard 6 does not apply to this service. Holmlea Care Home DS0000035767.V260492.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 Residents needs appeared well met, with evidence of the involvement of residents in care planning. EVIDENCE: The care records of four residents were examined. The records were well organised and easy to follow. All the records contained individual Personal Service Plans. The plans were detailed and comprehensive. The plans covered the assessed needs of residents and detailed the action required by staff to meet those needs. Two of the plans did not include details for staff of when and how ‘as required’ medication should be used. The plans included information on the preferences of residents regarding their daily routines. The plans were signed by the resident. The manager and a deputy manager had recently attended training about care planning and had clearly worked hard to put into practice the knowledge gained. The plans had been reviewed monthly, but the reviews were not signed. It was a requirement at the last inspection that all medication must be securely stored. This requirement had been addressed by the home by providing a
Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 10 separate medication fridge and lockable storage boxes for residents who wished to keep their own medication in their bedrooms. Records were kept of the daily temperature of the medication fridge, but not of the maximum and minimum temperatures as required to ensure safe storage of medication. Holmlea Care Home DS0000035767.V260492.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): 13 and 14 The home’s policies supported residents to have choice and control over their lives. EVIDENCE: The home had an open visiting policy. Residents spoken with said they could meet their visitors in their rooms if they wished and that visitors were always made welcome. Residents’ relatives or representatives were invited to resident meetings in the home and were encouraged to be involved in social activities in the home. Residents spoken with said they were able to bring personal possessions into the home. The bedrooms seen were well personalised with residents own pictures, ornaments and photographs. Residents said they were able to follow their preferred routines, such as times for getting up and going to bed. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 12 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 The robust complaints procedure and other opportunities to raise concerns ensured residents could be confident their complaints would be taken seriously. EVIDENCE: The home’s complaints procedure was displayed on each of the four wings and also in the main entrance area of the home. A complaints book was kept, but there were no entries made. Better use could be made of this book to detail informal complaints made, the action taken and the outcome. No formal complaints about the home had been received by CSCI since the last inspection. Residents spoken with were aware that they could complain if they wished. One resident had attended the last residents meeting and said this was a good opportunity to bring up any concerns. Minutes of the residents meetings were kept, plus records of any action taken to address the issues raised. Residents said they were happy to talk to staff about any concerns or complaints and felt confident that action would be taken. Staff spoken with said residents’ complaints were usually dealt with informally. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 13 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 The home was clean and generally well maintained, providing a pleasant environment for residents. However, the lack of progress in upgrading a bathroom was affecting the choice and service available to residents. EVIDENCE: The home was clean, well decorated and generally well maintained. A requirement was made in the last three inspection reports that the bathroom on green wing must be put back into use. The bathroom remained out of use on the day of this inspection. The manager said that it had been agreed to upgrade the bathroom, but no date for the work had been decided. There was a smell of cigarette smoke in the main entrance area of the home because of the open door to the staff room where smoking was allowed. The manager said that staff would not be allowed to smoke in the building from 1st November 2005. The gardens to the home were well maintained and accessible for residents. The home had won first prize in the inter-homes gardening competition this
Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 14 year. Photographs of the gardening project involving residents and staff were displayed in a scrapbook in the main entrance area. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 15 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, 29 and 30 Staff training and staffing levels were sufficient to meet the needs of residents. EVIDENCE: The home had recruited more staff since the last inspection and this had helped with covering staff holidays and sickness. Staff spoken with were pleased that new staff had been recruited and said that staffing levels were now generally satisfactory. At the last inspection it was a requirement that copies of the Criminal Record Bureau, (CRB), disclosures for staff must be kept in the home. The manager said that some progress had been made, but not all staff records had copies of the CRB disclosures. The requirement has therefore been carried forward in this report. There was programme of staff training in the home organised by the providers, Derbyshire County Council. Staff spoken with had attended training, such as first aid, fire safety, and NVQ training. New staff were undergoing induction training. Records were kept of training undertaken by staff, but there were no individual training and development records kept for staff. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 16 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): 35, 36 and 38 The systems in place in the home ensured that the safety and welfare of residents and staff was promoted and protected. Further development of the staff supervision programme was needed. EVIDENCE: The records were examined of residents’ personal money held by the home. The records were clear and well kept, with two signatures fore ach transaction and receipts kept. The money was kept securely in a safe in the office. One of the deputy managers was responsible for overseeing the system to ensure residents were safeguarded against financial abuse. It was a requirement at the last inspection that staff must receive formal supervision. A system had been developed and records were seen that some staff were having regular supervision sessions with senior staff. Some staff spoken with had not received regular supervision.
Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 17 The fire log book for the home was examined. This contained records of all the checks of fire equipment in the home and of the fire drills carried out. The records were clear and well kept and were all up to date. Other records relating to accidents in the home and other health and safety matters were all up to date. Standard 33 was not fully assessed at this inspection, but a requirement made at the last inspection was followed up. The requirement was that an effective quality assurance monitoring system must be in place in the home. The manager said that residents, visitors and staff had recently completed satisfaction questionnaires about the service and the results were being analysed and a report produced. To help with quality assurance monitoring, monthly resident meetings had been started since the last inspection. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 2 X 3 Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP19 Regulation 13(2) 23(2)(b) (c) 19(1)(b) Requirement The maximum and minimum temperatures of the medication fridge must be recorded daily The bathroom on green wing must be returned to practical use. Original timescale 30/12/03 Copies of staff Criminal Records Bureau disclosures must be kept in the home. Original timescale 31/08/05 Individual records of training must be kept for all staff at the home. Timescale for action 30/11/05 31/03/06 3 OP29 31/12/05 4 OP30 17(2) 31/03/06 Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP16 OP36 Good Practice Recommendations The complaints book should be used to record any complaints made, the action taken and the outcome. Staff should receive formal supervision at least six times per year. Holmlea Care Home DS0000035767.V260492.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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