Inspection on 10/02/06 for Holt House - The Salvation Army

This inspection was carried out on 10th February 2006.

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

Holt House - The Salvation Army 30/07/08

Holt House - The Salvation Army 12/07/07

Holt House - The Salvation Army 05/06/06

Holt House - The Salvation Army 15/07/05

Holt House - The Salvation Army 03/12/04

Holt House - The Salvation Army 28/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Salvation Army Holt House Headlands Drive Prestwich Manchester M25 9YF Lead Inspector Rukhsana Yates Unannounced Inspection 10th February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 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. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Salvation Army Address Holt House Headlands Drive Prestwich Manchester M25 9YF 0161 773 0220 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) Salvation Army Eva Ledson Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 32 service users, to include: up to 32 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 15th July 2005 Date of last inspection Brief Description of the Service: Holt House is a spacious, well-maintained property situated in a residential area of Prestwich. It provides personal care and support for up to 32 people over 65 years of age. The home is divided into three units, each with its own lounge and kitchen area. There is also a large communal lounge, dining room and conservatory. All but one room are single occupancy. Ramped access is provided to the front door of the home and ramps and a passenger lift are provided internally. There is a large garden area to the rear of the home which is well maintained. Level access is provided to a patio area where service users can sit and enjoy their surroundings. A conservatory, overlooking the garden is also provided. Parking for approximately 10 cars is provided within the grounds. Holt House is owned by the Salvation Army. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 6 hours. During the day, discussions about the standards of care took place with three residents, two visitors and two members of care staff. Some time was spent watching the manner in which staff supported residents. Care plans, staff records and other paperwork relating to the care and safety of residents were also examined. What the service does well: What has improved since the last inspection? What they could do better: Several improvements need to be made. Personal care and health needs should be clearly written and reviewed so that staff members can be sure they are providing the right care to every resident and they are not at risk of poor health. The risks of injury from bedrails needs to be reduced. Staff need to follow safe medication procedures. Strict background checks need to be carried out on new staff before they start work so that residents and relatives can be sure that suitable staff are being employed. The lift was out of order but due to be fixed. Fire safety checks need to be carried out regularly. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 6 More activities and good variety would make sure residents are involved in activities they enjoy. A plan is needed to show residents and their families how their views will affect the running of the home. Staff need regular opportunities to have individual meetings with their manager to make sure they understand and are carrying out their roles. The person in charge needs to manage the home better and make sure that the improvements needed are made. 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 Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 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 The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 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): The applicable key standard was not inspected during this visit. EVIDENCE: Standard 3 was assessed at the last inspection. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 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, 8, 9 and 10 Care plans need improvement to better reflect the health, personal and social care needs of residents so that needs and risks are known and responded to. Medication administration procedures need to be robust to ensure they are safe. Residents feel that, on the whole, they are treated with respect and their rights to privacy and dignity are upheld. EVIDENCE: Three care plans were examined and several shortfalls in the documentation identified. For example one had several blank sections in the personal care section and no date or signature for the assessment. Clearer instructions were needed for the care requirements rather than “needs assistance”. The information relating to hobbies and interests was sparse and there was no information under the heading of communication and understanding. Nutrition was identified as a “cause for concern” but there was no written plan to address this and no weight records. The second care plan was sufficiently completed in all areas with the exception of pressure area care relating to a skin break. The third was also well completed in the main, but the high The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 10 nutritional risk warranted regular and frequent weighing and a detailed intake record, both of which were not in place. The greatest cause for concern related to the use of bed rails on some beds which were not risk assessed, did not have written instructions for use and were badly fitted to divan beds. These greatly compromised the safety of residents and were required to be removed on the day of the inspection. Residents requiring bed rails must have a full and proper risk assessment in place and rails must be suitable for the bed. Full supporting documentation must be in place to justify their use in each individual case. With respect to medication, storage arrangements appeared satisfactory, but there were unexplained gaps noted in the medication records. One member of staff had signed the medication administration record when another staff member had administered. Another resident was given their medication late and this had been potted and left in the unit kitchen cupboard. The home needs to ensure that medication procedures are safe and that accurate medication records are kept. Residents were consulted with regard to the attitudes of staff. They felt that their right to privacy was upheld, and that staff were “very good” on the whole. Two said that “it depends” making the point that some staff have a more gentle and patient attitude than others. This issue was raised at the previous inspection when an instance of poor staff attitudes to residents was observed. At this inspection, some good practice was observed, with staff members showing kindness and sensitivity in their interactions. However, the issues relating to values in practice need to be better reflected in training and supervision arrangements in light of previous findings. Team meeting minutes highlight the need for staff to improve attitudes, but this must essentially be reinforced by management and ongoing observations made of practice to ensure that respectful attitudes are in evidence at all times. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 An increase in recreational activities and a programme of activities based on the individual needs and preferences of residents is required. Open visiting arrangements ensure that residents may see friends and relatives when they wish. Residents have choices in their daily routines as far as possible. EVIDENCE: Residents consulted said they have a choice in their daily routines, including what time they get up and go to bed, where to spend their time and which activities to take part in. Observations made during the day confirmed that residents can have a lie-in and late breakfast if they wish. There are regular prayer meetings and, in the past, a satisfactory range of activities. However, at the time of this inspection, the lift had been out of order for a number of weeks awaiting a part to enable it to be repaired. This had resulted in, as one staff member said, activities “coming to a standstill”, although sing-a-longs and some armchair exercises had taken place. The home needs to put a structured activity programme in place and implement it in order to meet the recreational needs of residents. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 12 The home has open visiting arrangements and residents are able to see their relatives in private. Relatives consulted confirmed that outings take place, and examples including Blackpool and attendance of the Over 60’s club were given. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Written guidance and training arrangements ensure that staff members have a good knowledge of abuse and protection arrangements and safeguards in place to protect the welfare of residents. EVIDENCE: Holt House has an abuse policy common to all Salvation Army residential care homes for elderly persons. In the ‘Handbook of Employment’, which all staff have access to, is a separate whistle-blowing policy, the aim of which is to ‘create a culture whereby staff can feel confident about raising concerns of wrongdoing within the work place’. The Quality Standards manual has ‘Guidelines For Recognising and Dealing with Abuse of Elderly and Vulnerable People’, which also covers financial abuse. In addition, a copy of Bury’s Interagency Abuse procedure is held on site. Staff consulted confirmed that they had received training and were aware of the whistle-blowing policy. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Residents benefit from a pleasant, clean and well maintained environment. There is a need to make sure all fire safety checks are kept up to date to ensure safety. EVIDENCE: The location and layout of the home is suitable for its stated purpose. It is accessible, safe, and well maintained. Externally there is an easily accessed, large, pleasant and well maintained garden area. Internally the home is spacious, with easily accessed recreational areas, with bedrooms suitable to service-users’ needs. The manager makes note of areas in need of maintenance and renewal and addresses them as finance becomes available. Smaller maintenance matters are addressed as they arise. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 15 Service-users have access to all areas of the home by the provision of ramps and passenger lift, although this was awaiting repair at the time of the inspection. There is an alarm call system with long leads provided in bedrooms to enable service users to use them when sat in chairs. Handrails, grab rails, raised toilet seats and hoists are provided. The home also has two electric hoists to better meet service user needs. A loop system is provided in the main lounge area and there is ample storage space for wheelchairs. Arrangements for ensuring fire safety were generally satisfactory. However the fire precautions register indicated that some checks were not being carried out at the required intervals. For example the weekly means of escape check was last carried out on 13.1.06 and the last emergency lighting check on 4.11.05. All checks must be carried out at the required intervals and records kept to ensure fire safety is maintained. The home was clean and odour free, with suitable infection control measures in place. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 Recruitment procedures do not include the proper checks necessary to be considered safe. Staff training arrangements ensure that staff receive the training they need to carry out their role. EVIDENCE: Staff recruitment procedures require urgent attention. One of the two staff files examined showed that the staff member had declared that she had no criminal record but the CRB showed convictions. There was no evidence of discussion with the staff member about this. One reference did not match the named referee. In addition a reference was not taken up from the more recent employee, which would have been pertinent as it was a nursing home the applicant had worked at. Another file showed that the reference did not match up with the named referee and the application form had not been fully completed. Recruitment procedures must be demonstrably robust to protect the welfare of residents. Staff members consulted confirmed that they receive training in mandatory topics such as moving and handling and first aid, and several staff were reported to be working towards NVQ qualifications. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 17 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): 31, 33, 35 and 36 The registered persons need to ensure that management of the home is effective, and that requirements are met and standards adhered to in order that residents are safe and their needs fully met. A quality improvement plan is needed that shows residents, their relatives and others how their views affect the way the service develops. Residents’ finances are safeguarded and well managed. Regular supervision meetings need to take place with all staff members to ensure their development needs are being met and practice monitored. EVIDENCE: The manager is experienced, has achieved the NVQ Level 4 and is a qualified NVQ Assessor. As she was involved in her assessor role during the inspection, it was not possible to fully assess this standard. Staff reported that the manager is approachable and that regular team meetings take place. However, there are concerns that there continue to be a number of The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 18 requirements arising during inspection visits, and the management role is not being carried out effectively. With regard to quality assurance, the manager said that that questionnaires are being devised. Questionnaires, meetings and discussions are needed involving a range of stakeholders in order to gain views to inform an annual quality improvement programme for the home. Examination of the system for managing residents’ finances showed that there are good, clear and well organised accounting systems. The administrator was advised to instigate a social work review for anyone not receiving their allowance from relatives. Health and safety inspection certificates were not examined at this inspection. Staff supervision records were examined. One file contained brief supervision notes for one meeting, with no further meetings since September 05. Other files showed that supervision meetings were not taking place regularly. Meetings and observations are needed to ensure there are good staff attitudes towards residents at all times. The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X X The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 20 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. Standard OP7 Regulation Requirement Timescale for action 03/04/06 2. OP8 3. 4. 5. 6. OP9 OP12 OP19 OP29 12, 13, 15 Care plans must be fully completed and followed in respect of care to be provided. All risks must be documented and appropriate action taken. 13, 14, 15 In order to ensure adequate nutritional intake, those at risk must be regularly weighed and closely monitored and reviewed. A dietician referral should be made if necessary. The home must also complete pressure area risk assessments for residents so that prevention measures can be put in place for those at risk of developing pressure sores. (previous timescale of 12/09/05 not met) 13 Medication procedures must be followed and accurate administration records kept. 16 A suitable activities programme must be implemented and maintained. 23 Fire safety checks must be carried out at the prescribed intervals. 18 Recruitment procedures must ensure that all necessary checks DS0000008477.V282284.R01.S.doc 03/04/06 10/02/06 17/04/06 03/04/06 10/02/06 The Salvation Army Version 5.1 Page 21 7. OP31 9 8. 9. OP33 OP36 24 18 are carried out and the shortfalls identified are rectified. The registered person must 17/04/06 ensure that management arrangements are effective in addressing shortfalls and maintaining standards. A quality improvement plan must 05/06/06 be produced and implemented Suitable individual supervision 30/05/06 arrangements must be in place for each member of staff. 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 The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 The Salvation Army DS0000008477.V282284.R01.S.doc Version 5.1 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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