Inspection on 12/07/07 for Holt House - The Salvation Army

This inspection was carried out on 12th July 2007.

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

Holt House - The Salvation Army 30/07/08

Holt House - The Salvation Army 05/06/06

Holt House - The Salvation Army 10/02/06

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 Mike Murphy Unannounced Inspection 12th July 2007 09:30 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.V337580.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. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 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) eva.ledson@salvationarmy.org.uk 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.V337580.R01.S.doc Version 5.2 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. 29th November 2006 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. The Salvation Army owns Holt House. The fees at the time of inspection were £355.11 to £515.42per week. (Information supplied by the provider). The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which the manager did not know was going to take place, is the first conducted since January 2006. This inspection was conducted on the 12th July 2007 between 9am and 2.30pm. And included discussion with residents and relatives, the registered manager, regional manager and home staff, inspection of the premises, inspection of records maintained by the home in relation to how residents are cared for, supported and protected. Views have also been expressed in comment cards returned to the CSCI prior to the inspection and these are also reflected in the report. What the service does well: What has improved since the last inspection? What they could do better: Whilst the contents of care plans have improved there is a need to formally evaluate these more frequently. This is also the case with risk assessments. The regular review of care plans and risk assessments can only help protect the health and welfare of residents as much as possible. There is also a need to implement a system of quality assurance at the home to fully assess how satisfied people are with the service provided and to measure how effective the procedures and systems operated at the home are (for example a regular audit of care records would identify issues regarding care plans and risk assessments). The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 6 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. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 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.V337580.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have their health and care needs assessed before their admission to the home and this gives an assurance both to residents, relatives and staff, that a person is only admitted if the home can meet their needs. EVIDENCE: All prospective and existing residents are provided with a ‘service users guide’ that includes a range of information about the home, the services provided, the experience and qualifications of the staff, the most recent inspection report, and how to complain about the service if necessary. Residents indicated they were aware of this document (as were the relatives spoken to) and that a copy was in their room. It is noted that the statement of purpose produced by the home needs to be reviewed to reflect recent changes in the way the home is being managed by the manager and staff. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 9 Inspection of 3 resident’s care files showed that before they were admitted to the home after an assessment of their needs had been undertaken by a senior member of care staff from the residential unit. However 2 of the assessments had not been signed or dated. The manager, to ensure they are fully completed, should periodically audit these records. The resident files also contained assessments undertaken either by the residents’ social worker or from the hospital they were admitted from. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 10 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): 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents were in the main being addressed appropriately. However some issues were identified in respect of record keeping and resident’s medication. EVIDENCE: The care records of 3 resident’s were inspected in detail. These contained assessments of need, care plans, risk assessments, and daily statements. The structure of care plans have been reviewed since the last inspection and reflect what actions staff need to take to care for and support residents appropriately. However whilst care plans are periodically being reviewed and re-written they are not in the main being formally evaluated (at least on a monthly basis) – it is good practice to do so and it is strongly recommended this should become normal practice. Risk assessments for moving and handling and nutrition (including weight monitoring and the risk of pressure sores) were generally The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 11 completed. It was noted however that one resident had no recorded weight since being admitted in the spring of 2007 – this is a key observation and needs to be conducted on a regular basis as part of a nutritional assessment. Whilst risk assessments are in place as with care plans they are not in the main being formally evaluated at least on a monthly basis – once again it is good practice to do so and it is strongly recommended this should become normal practice. It is also recommended that the risk of pressure sores should form a separate risk assessment. The inspector discussed these issues with the registered manager and her regional manager during the course of the inspection. The inspector was informed these issues would be addressed and care records will be audited as part of the quality assurance process of the home. The procedures for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate. No residents were managing their own medication at the time of this inspection. Senior care staff are responsible for all aspects of managing medication in the home – all have been trained by Boots in the management of residents medication. Medication administration records had mostly been completed appropriately. However it is strongly recommended where staff make written entries on medication administration records 2 staff check and sign the entry. Residents who require insulin injections receive these from the district nurses who visit twice daily to provide this service when necessary. The district nurses also provide any other nursing care/support resident’s may require for example dressings. Discussion with residents revealed satisfaction with the care and support they are provided with. And that they are able to access health and social care services as they require. All residents are registered with a local GP and it was evident that all were enabled to access optical, chiropody, dental, district nurses and other specialist services as required. Relatives spoken to during the inspection said that they were contacted regarding all significant changes in their relative’s condition. Residents reported they are treated respectfully and that their right to privacy is maintained. Comments made included; ‘the staff are very considerate and speak to me properly’, ‘I was asked what I wanted to be called when I first came to live her’, ‘the staff try to make sure I am covered up properly when the help me so I don’t feel embarrassed’. Medical (and other) consultations are conducted in the privacy of each resident’s room. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 12 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): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to enjoy a stimulating lifestyle with a variety of options to choose from. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. EVIDENCE: A prominently displayed activities programme identifies varied activities that resident’s can choose to participate in. Residents identified the things they enjoy at resident meetings and felt they were enabled to participate or not as they chose to. Those spoken to said that the daily routines were as reasonable as possible in a communal living setting. Residents confirmed – and this was also reflected in care records – that they can choose when they get up and go to bed, how they occupy themselves and retain as much control over their personal lives as they desire or are able to. Many have chosen to highly personalise their own rooms with their own possessions – including items of furniture. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 13 Residents and their relatives report no unreasonable restrictions to visiting at the home – which can be conducted in communal lounge areas or service users bedrooms. Residents continue to be encouraged to maintain contact with the local community – e.g. local churches, over 60s club. Menus were balanced, varied and provided reasonable choices. Three meals a day are provided plus supper. Meals are served in a pleasant and appropriate dining area. Meal times are reasonable and as flexible as they can be in such a setting. Lunch was observed on the day of inspection. This was a hot and substantial meal.(Meals are cooked in the home by a catering company contracted specifically for that purpose. The local Environmental Health Officer inspected the kitchen in January 2007 and no issues were identified. Staff assisted and served residents their meals appropriately. Residents spoke positively about the quality of the food provided and said their particular likes and dislikes were respected and that staff always tried to accommodate them with particular catering requirements. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 14 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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an appropriate complaint procedure and protection systems in place to ensure residents are safe. EVIDENCE: The complaints procedure was prominently displayed in the home. This document explains in clear terms how to make a complaint and who to contact. Residents and relatives spoken to say they were aware of how to make a complaint if they felt it were necessary. Those spoken to who have had cause to make a complaint felt their issues were listened to, examined properly and responded to in a reasonable time. However in the main many issues are resolved swiftly and informally without going through the complaints process. The registered manager keeps a record of all complaints made, how they have been investigated, the outcome of the investigation and the response provided to the person who has complained. Holt House operates protection of vulnerable adults and whistle blowing policies that seek to protect elderly people. In addition, a copy of Bury’s Inter agency protection procedure complements the home’s policies. Staff spoken to confirmed that they had received adult protection training (this was reflected in training records maintained by the home) and were aware of the whistleblowing policy. Appropriate pre-employment checks are conducted on all staff to ensure suitable people look after the resident’s. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 15 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): 19,20,21,22,24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appeared to be structurally well maintained throughout and provides a suitable and comfortable environment for the care of residents. EVIDENCE: Holt House is pleasantly situated in set in well-kept grounds and gardens that are accessible to residents. A tour of the premises as part revealed that the home was very clean and free of malodour. The lounges and dining room provide spacious, appropriate, comfortable and warm communal areas for residents. WC and bath/shower rooms were appropriately equipped and adapted to meet the health and safety needs of residents. Six bedrooms were inspected on this The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 16 occasion – these were clean, warm, suitably ventilated, personalised, comfortable and appropriately furnished and equipped. A programme of maintenance and refurbishment has been developed and implemented. Residents are encouraged to bring personal items into the home and this creates a more personalised atmosphere in resident’s own rooms. Discussion with residents and their relatives revealed that the home is cleaned to a very high standard at all times. Appropriate measures to prevent the spread of infection were in place – including adequate hand washing/cleaning facilities, laundry and sluicing arrangements, provision of disposable gloves and aprons for staff, adequate provision of house keeping staff and appropriate arrangements for the disposal of clinical and other waste. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 17 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): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment, provision and training of staff employed at the home are being managed appropriately. This is important to ensure that residents are being cared for adequately and appropriately by staff that are able to deliver this support safely and competently. EVIDENCE: Inspection of staffing rotas indicated that staffing provision at the home complied with the current minimum requirements that apply to care homes for older people. Discussion with manager and staff at the home indicated that they were of the view that staffing levels were appropriate to meet the dependency levels and needs of resident’s. There is also adequate provision of housekeeping, catering and ancillary staff at the home. Inspection of 3 staff personnel files revealed that these contained an application form (including health declaration and detailed work history), 2 written references, a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity and evidence of induction and other training. There is strong NVQ, mandatory and other training provision for all staff at the home. Training records are detailed and organised and discussion with staff indicated that they are enabled and supported in accessing appropriate training to look after their residents effectively and safely. All staff employed at the home are The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 18 provided with appropriate induction training. A review of staff training is conducted as part of the regular individual staff appraisal conducted by the registered manager. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 19 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): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holt House was being appropriately managed in a way that enables residents, their relatives and staff to feel that they are being supported properly. EVIDENCE: The registered manager is experienced, has achieved the NVQ Level 4 and is a qualified NVQ Assessor. Discussion with residents, their relatives and staff indicate that the manager operates a management style that is open and accessible. The home was well organised with a clear management structure (which has been reorganised since the last inspection). The manager is supported by a team of principal senior carers and care staff. There is also full The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 20 time administrative and maintenance support. Catering and domestic personnel are supplied through a company contracted for these services. The manager and her regional manager have developed a quality assurance system to measure resident’s satisfaction, with the level of care and accommodation they are provided with. This is essential as such information will enable a quality improvement plan to be fully developed and implemented to further improve the quality of life for residents. The inspector was informed that is to be implemented in the near future. Measures were in place to ensure that residents’ financial interests are safeguarded. Residents are encouraged to control their own money. However where they are unable (or choose not to) personal allowances are managed by the home. The arrangements for this were secure and appropriately documented. The health, safety and welfare of residents and others are promoted and protected. For example staff are provided with regular training and appropriate equipment to ensure resident’s moving and handling needs are met. An example of this would be for a resident who needs to be safely moved with the aid of a hoist. Fire safety training is regularly provided. Information provided by the home indicates that gas and electrical safety inspections/servicing have been carried out. It is noted that some remedial electrical work was due to be carried out after this inspection. The passenger lift that enable residents and others to access all areas of the home has been serviced as has all hoisting equipment used in the home. All significant events in the home – including accidents and illness and monitoring visits by the home’s owners – are recorded and reported (as required legally) to the CSCI. The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 21 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 2 X 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 22 e Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4,5 and 6 Requirement That you update the statement of purpose and service users guide to reflect changes made to the way staffing is structured in the home. Copies of the amended documents should be provided to the CSCI. That the CSCI is informed in writing that as part of nutritional screening a record of weight loss/gain is maintained for each resident. That the CSCI is provided with a report detailing how quality of care at the home is assessed (including how the views of residents and their representatives is obtained) That the CSCI is informed in writing that the remedial electrical work that was due to be carried out after the date of this inspection has been completed. Timescale for action 30/09/07 2 OP8 12 30/09/07 3 OP33 24 30/09/07 4 OP38 13(4) 30/09/07 The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 23 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 OP3 OP8 Good Practice Recommendations That all pre-admission assessments are signed and dated by the person conducting the assessment. That a separate risk assessment is developed in respect of resident’s risk of developing pressure sores. That all residents care plans and risk assessments are formally reviewed at least monthly. It is strongly recommended in the interests of safety where staff make written entries on medication administration records 2 staff check and sign the entry. 3. OP8 4. OP9 The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 The Salvation Army DS0000008477.V337580.R01.S.doc Version 5.2 Page 25 - 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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