Inspection on 25/01/07 for Holmleigh

This inspection was carried out on 25th January 2007.

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

Holmleigh 03/01/06

Holmleigh 27/07/05

Holmleigh 22/02/05

Holmleigh 02/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Holmleigh Lincoln Road Navenby Lincolnshire LN5 0LA Lead Inspector Mr Toby Payne Key Unannounced Inspection 25th January 2007 08:20 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 Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmleigh Address Lincoln Road Navenby Lincolnshire LN5 0LA 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) 01522 810298 homeleigh@accreit.co.uk Lincolnshire Property Investment Fund Limited Mrs Hazel Lynne Carelton Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (1) of places Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Old age, not falling within any other category (OP) (33) Physical Disability (PD) (1) The maximum number of service users to be accommodated is 33. The category PD applies to service users aged 60 years and over. Only rooms in excess of 12 sq.m. will be used to accommodate service users within the PD category. 3rd January 2006 2. 3. Date of last inspection Brief Description of the Service: Holmleigh is situated a quarter of a mile from the centre of the village of Navenby, which is about seven miles from the city of Lincoln. Navenby has a range of amenities including shops, a public house, church, chapel and a coffee shop. The home is registered to provide personal care for up to thirty-three people of both sexes aged over 65 years, in thirty-one single and one double room, all with en-suite facilities. On the day of the inspection there were 32 people living in the home. The home is a former private house, which has been adapted and comprehensively extended. Twenty-six of the bedrooms are on the ground floor, all with patio doors leading into the garden; five single rooms and one double room are on the first floor of the older part of the house. A passenger lift provides access to these rooms. Other facilities in the home include a hairdressing room and a small library. There are three lounges and a dining room, all on ground floor. There is ample car parking for visitors to the side and rear of the home. The patio areas and landscaped gardens are attractive, colourful and easily accessible to the residents. The homes philosophy is that people are given dignity, respect and choice to be as independent as possible. The fees at the inspection on the 25/1/2007 ranged from £335 to £450 each week. Extras are for hairdressing which range from £6.50 to £18, chiropody £7, toiletries, personal newspapers and magazines. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and started at 8.20 am. It was undertaken using a review of all the information available to the inspector about Holmleigh Care Home. It took place over 5½ hours. The inspector spoke to 11 residents, 4 visitors, 5 staff, the deputy manager and manager. The main method of inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of their care. The inspector also examined a pre-inspection questionnaire, which had been completed by the manager. Comment cards were received from 21 residents. What the service does well: What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 6 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 Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People coming into the home receive information to allow them to make a choice whether or not to come to the home. People are assessed by a competent person before coming into the home. EVIDENCE: The statement of purpose and service user’s guide were comprehensive documents, which described clearly what was available at the home, its philosophy of care and how the home met the needs of the residents it accommodates. Both documents were reviewed in January 2007. A copy of the service user’s guide was given to each person. Copies of both documents were displayed in the entrance to the home. Records from 2 residents showed that they had received a detailed assessment by the manager before coming into the home. They had also been involved in the assessment. Records were very detailed and written confirmation that the home could meet their needs was sent to each person. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 8 One resident knew the home and made her own decision to come into the home. Both residents felt they had settled in the home well. The home did not provide intermediate care. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are easy-to-read documents that clearly describe the care that staff need to provide, are kept up-to-date, reviewed regularly and show evidence of resident or relative involvement where possible. EVIDENCE: Residents had a file with a care plan outlining their care and welfare needs. Care records for 2 people were examined. The records included pre-admission assessment and care plan for each aspect of daily living including nutrition, mobilisation, sleep, moving and handling, continence, weight record, detailed risk assessments, falls risk assessment and safe environment. Records were very clear and person focused. They were produced with the involvement of the resident/relative and reviewed regularly. The care records were audited monthly by the manager as part of its quality system. The home had detailed policies and procedures for the administration of medication. There were 8 named people who had been assessed as being safe to administer medication. They had also received training. The manager Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 10 audited every month 10 resident’s medication records. The audits were clear and detailed and showed no concerns. A medication round was observed during the inspection. There were no concerns. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a lifestyle, which takes into account and suits the needs and wishes of the residents. Residents receive varied and nutritious meals. . EVIDENCE: The home employs an activities co-ordinator 16 hours a week (4 hours a day for 4 days a week). Each new person was seen by the activities co-ordinator and information was obtained about their likes and dislikes, interests and “this is your life” (information about the person’s life) was completed by the resident, relative or with the member of staff . There was a wide range of activities provided including quizzes, church services (currently Methodist and Church of England but other denominations would be arranged). On the day of the inspection communion was being delivered to the residents. Other activities included library, church, games, scrabble, board games, outings, crafts, bingo and piano in one of the 3 lounges. Residents were also were encouraged to attend village activities and Women’s Institute meetings and maintain interests and hobbies. There was a monthly newsletter and photographs were displayed of activities, which had taken place. Residents Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 12 were very satisfied with the range of activities. Visitors were made to feel welcome. The menu was displayed on the notice board in the corridor leading to the dining room. Residents spoke of their being a choice and enjoying the food served. Residents commented, “we enjoy the food, we are asked what we wish to eat and there is choice”. Information about resident’s food preferences was passed on to the catering staff. Lunch was observed being served by staff from a trolley to residents who were sat at the tables, which were laid with clean tablecloths, place mats and cups and saucers. Staff were efficient and the room was full of laughter and conversation. The inspector also saw a member of staff attending to one resident who did not come to the dining room but sat in one of the lounges. The member of staff knelt in front of the resident and fed the person explaining what she was doing and doing this in a kind, patient and sensitive manner. The catering staff had received food hygiene training. Staff were appropriately dressed and North Kesteven District Council awarded the home 4 stars for its catering service in August 2006 (the award was displayed at the entrance to the home). Monthly audits were made by the manager of catering. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints received were treated properly and residents and visitors knew that any complaints they had to make would be addressed and taken seriously. Staff were recruited correctly to ensure that residents were protected from abuse. EVIDENCE: Each person received a complaints procedure in the service user’s guide. No complaints had been received by the home or the commission since the last inspection. The home had a copy of Lincolnshire County Council’s adult protection procedure. The commission was aware of a recent allegation, which had been made, and of the investigation, which was taking place regarding a safe guarding adults incident. Lincolnshire County Council was investigating this with the full co-operation of the home. None of the residents, relatives/visitors or staff had any concerns about the home. Two staff records were examined. Records were well maintained and included evidence to show staff had been recruited correctly with a check by the Criminal Records Bureau (CRB). A member of staff confirmed this and spoke of the supported induction she had received and that she liked working in the home. Staff had also received training about adult protection and spoke of what they would do if abuse was suspected. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents lived in clean, well decorated, homely and safe accommodation. Any maintenance was promptly addressed. EVIDENCE: There is an 11 bed extension planned with new lounge and bathroom. There were three lounge areas and other seating areas where people could sit and well maintained accessible garden areas. Many of the rooms overlooked the garden areas. Resident’s rooms were very individual with items of furniture, pictures, televisions and personal mementoes. All bedrooms were en-suite. Residents said how much they liked their bedrooms. Residents commented, “my room is very comfortable with my own things and furniture”. Clear records were being kept of any maintenance carried out or equipment serviced. Hot water temperatures were also tested monthly and records showed temperatures ranged from 39.8 to 45.6º Centigrade. This was a safe range. Records were well maintained. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 15 All areas of the home were clean, tidy and well maintained. The home had procedures and equipment in place to ensure that it was hygienic, safe and “had a pleasant atmosphere”. Radiators were covered to protect the residents from the risk of harm. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment policies and practices of the home ensured that the residents are cared for safely and are protected from harm. Staff knew what they were doing by being trained to carry out the care and support for people in the home. EVIDENCE: The home employs separate staff for care, catering, laundry, domestic, maintenance and administration. A deputy manager assisted the manager. The procedures in place for the recruitment of staff were robust. Records were checked for 2 staff and seen to well maintained. The duty rotas were examined and showed there were sufficient numbers of staff in the home to meet the needs of people living in the home. The manager monitored the needs and arranged for additional staff to be provided where required. None of the residents, relatives/visitors and staff had any concerns about the levels of staff. Staff spoke of having time to care and support the residents. Staff were seen to promptly attend to the needs of people. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 17 Staff spoke of the training received which included, moving and handling, Control of Substances Hazardous to Health (COSHH), first aid, dementia awareness, diversity and equality, fire prevention, record keeping, care practices and NVQ. Staff spoke of the benefit they had received from the training. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has an experienced, competent manager who communicates well with all in the home. There are excellent and detailed quality assurance systems, which ensure that the health, safety, care and welfare of residents are maintained. EVIDENCE: The manager is a registered nurse, has a management qualification and is a very experienced manager. Policies and procedures had been reviewed by the operations director in 2006 and were very detailed and comprehensive. The manager acknowledged that not all staff were receiving regular staff supervision and agreed to address this. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 19 There was an extensive and comprehensive quality assurance system, which included a residents survey every 3 months. 13 were sent out in June 2006 and 7 returned. An analysis was then made which was sent out in the monthly newsletter. Positive responses were received. A future survey was to be sent out. Lincolnshire County Council had a contract review on 11/1/2007, which was very successful. In addition, internal audits were carried out for catering, care plans, medication, maintenance and tissue viability. Records were very well maintained. The regional manager made monthly visits to the home and comprehensive reports were sent to the commission. There was an equal opportunities and diversity policy and this was also referred to in the staff handbook. In addition, a number of staff had attended training on equality and diversity. There were no issues of concern and no communication issues. Staff, relatives and residents had confidence in the manager and staff were seen to communicate with one another and the manager in a professional manner. Relatives commented, “excellent, I have been very impressed and I am very satisfied with the care”. The home had detailed health and safety procedures. There were also infection control policies and staff made use of alcohol hand rub bottles throughout the home to further prevent infection. Where required risk assessments had been carried out and documented. There were a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm; fire drills and emergency lighting checks and testing of hot water have been undertaken. Care staff also received fire training as part of the homes initial training and as a regular training event. Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 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 3 X 3 x X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 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 © 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 Holmleigh DS0000002374.V327234.R01.S.doc Version 5.2 Page 23 - 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. 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