Inspection on 27/07/05 for Holmleigh

This inspection was carried out on 27th July 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holmleigh 25/01/07

Holmleigh 03/01/06

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 Vanessa Gent Unannounced 27 July 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holmleigh Address Lincoln Road Navenby Lincolnshire LN5 0LA 01522 810298 01522 810827 homeleigh@accreit.co.uk Lincolnshire Property Investment Fund Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Hazel Carelton Care Home 33 Category(ies) of Old Age (OP) - 33 registration, with number Physical Disabilty (PD) - 1 of places Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 22/02/05 Brief Description of the Service: Holmleigh is situated a quarter of a mile from 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 coffe 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 rooms, all with ensuite facilities. 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. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7½ hours. The inspector spoke with four residents, three visitors and three staff as well as the manager. Nineteen comments cards were received from residents and/or their representatives. Ten had extra comments, eight of which were very positive and two which expressed concerns about the lack of security at the front door. The main method of inspection was called “case tracking”. This involves selecting a sample of residents and tracking the care they receive through the checking of records, discussion with them and the care staff and observation of the care provided to the residents. What the service does well: What has improved since the last inspection? Staff are now recruited safely. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4, 5 Pre-admission assessments and good liaison with other social and healthcare professionals enable the manager and staff to assess and meet the needs of the residents. People are welcome to visit the home on a trial basis. EVIDENCE: The terms and conditions contract contains the number of room to be occupied and shows in involvement of the residents or representative. A copy is kept on file. Pre-admission assessments are comprehensively undertaken for each prospective resident and the manager confirms in writing that the home can meet their needs, as seen in the care plans of a recent admission to the home. A relative confirmed that the manager and staff are meeting the needs of the resident as outlined in the initial assessments and the care plans. A written comment received from a relative states, “Holmleigh have worked really hard to welcome my mother and make her feel at home so well done to them.” Residents and relatives state that they have visited the home prior to making any decision to stay on a long-term basis. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 Good documentation in the care plans and communication with healthcare professionals enable staff to meet the needs of the residents and provide the care they require. Medication practices are excellent with staff being well-supported in training and supervision by the manager. Dignity and respect is afforded to residents and relatives alike. EVIDENCE: Care plans are in neat sections, clear, well-described, well-documented and easy for staff to follow. They give an holistic view of the lives of the residents. Care plan issues identified are carried out by staff, ensuring that the residents’ changing needs are met. Advice is taken from the community tissue viability nurse and staff have regular contact with the surgery practice nurse for a resident with diabetes. A relative confirmed that any healthcare issues or concerns are dealt with by the manager without delay and the relative is informed of any change in the resident’s condition at all times. Medication practices show accurate records, evidence of drug administration training, a good knowledge of medicines and the residents being displayed by administering staff. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 10 Residents say they are treated with dignity and their privacy is respected. This was confirmed during the inspection by staff who were seen to knock on residents’ doors and speaking with residents and relatives in a jovial and pleasant manner at all times. A letter from a relative commented that residents are treated as individuals, with respect, dignity and affection, even when residents have displayed unacceptable behaviour. “Mum is happy there.” Another comment received said, “Father has never been as well as since coming to the home.” Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15 The activities provided are varied and suit the needs and preferences of the residents. The staff and manager are welcoming, hospitable and jovial. Contact with family, friends and community is encouraged. The food caters to the varying needs and tastes of the residents. EVIDENCE: Evidence of a variety of activities was seen at the inspection and confirmed by residents spoken with. Special occasions are celebrated and enjoyed with visitors always invited and welcome to join in. Relatives say they are welcomed at the home. The manager was seen to warmly greet every visitor during the inspection and a relative confirms this is usual practice. The food is “good and varied”, looks appetising and nutritious, with home cooking and fresh fruit and vegetables always in ample supply. Residents choose for themselves at each mealtime. One relative stated that her mother regained her previous lost appetite and weight after admission. Relatives enjoy joining the residents for meals, especially at festive seasons. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 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 standard(s) 16, 17, 18 The manager and staff demonstrate a caring and knowledgeable attitude, which enables residents to feel protected and safe and gives confidence to relatives that the residents are well cared for. Residents’ rights are protected. EVIDENCE: The Complaints policy notice is clearly displayed and contains the required information for any person wishing to raise a concern or complaint. No complaints have been received by the home or the Commission in the past twelve months. Many compliment letters and comments have been received by the manager. Leaflets for an advocacy service are available in the entrance hall. Ninety-eight percent of residents took part in the last election, some using the postal facility, others being taken to the local polling station. Postal voting application forms are completed on admission. All staff are up-to-date with training to protect vulnerable adults and preventing abuse. Residents say they feel protected and safe with the caring staff and manager. In the comment cards, relatives praised highly the management of all aspects of the home. They say the attitude of the staff is wonderful, caring, kind, attentive and respectful. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 22, 24 The residents live in a clean and safe environment with adequate facilities for comfortable living provided. EVIDENCE: Although security of the premises has been a concern for two relatives, the manager regularly risk assesses the premises in relation to the category of residents the home can and does accommodate and believes that all residents are safe within the home’s present security system. Both private and communal accommodation is spacious, well-presented and comfortable. Residents’ rooms are personalised, light and airy. All are ensuite. Comments received say, “Perfect, class A home.” “The best”. The garden is highly colourful with many flowers, especially outside bedroom patio windows and enjoyed immensely by residents spoken with. There is ample car parking space for visitors. Specialist equipment such as airflow mattresses and pressure-relieving cushions were seen appropriately in use for residents who were case-tracked. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 30 The adequate numbers, skill mix and positive, happy attitude of staff on duty at all times ensures the safety and welfare of the residents. EVIDENCE: Staff duty rotas examined indicate that an adequate number and skill mix of staff are on duty at all times. A high proportion of staff have undertaken and are currently studying for National Vocational Qualifications at all levels, with four staff currently completing NVQ level 4. All staff spoken with are enthusiastic about training and gaining qualifications and say the manager is encouraging. Mandatory training has been undertaken or is booked to take place in the coming months for all staff and training is updated regularly. A staff training matrix, publicly displayed in the office, clearly demonstrates the courses undertaken and future training needs of all staff. Many compliments and positive comments were received about the caring, loving, respectful and jovial attitude of staff and the manager towards the residents and visitors to the home. “Staff and manager are really aware and ‘on the ball’ as far as care goes.” Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37, 38 The manager is experienced, competent and communicates well with residents, relatives and staff. She ensures that the service provides safe practices and that the health, safety and welfare of the residents are maintained. Good auditing and monitoring and involvement of residents in the running of the home ensures that their rights are protected and the home is run in their best interests. EVIDENCE: The manager qualified as a nurse in 1979 and has had almost continuous nursing or care home experience since that time. She has undertaken and continues to take further training in tissue viability, continence, social care (activities), management and other relevant courses. A relative wrote on the comment card, “The manager is the key to the high standards and happy atmosphere exhibited by the well motivated staff.” Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 16 Another commented “She runs a tight ship but has the respect of her staff for it.” Residents’ finances are protected by robust and stringent record-keeping by staff and monitoring by the manager. To ensure the consistency of care and attention for all residents, the manager monitors, audits and supervises the service provided and staff, as seen in documentation examined. The regional manager visits the home and submits monthly reports of the running of the home. The residents, staff and relatives are involved in the running of the home through staff, residents and relatives’ meetings, questionnaires and day to day communication. Record-keeping is meticulous: easy to locate, to follow and ensures that all practices, equipment and facilities in the home are robust and safe. All health and safety practices are in place, including staff training, regular maintenance, fire awareness, hygiene and reporting of incidents, accidents or injuries to ensure that residents are protected. Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 x 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 x 15 3 COMPLAINTS AND PROTECTION 4 3 x 3 x 4 x x STAFFING Standard No Score 27 3 28 4 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 4 4 4 x 3 3 3 3 Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 23(3a) Requirement Suitable facilities and accommodation must be provided for the use of staff. Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Unity House, The Point Weaver Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holmleigh C53 C04 S2374 Holmleigh V240834 270705 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!