Inspection on 30/07/08 for Holt House - The Salvation Army

This inspection was carried out on 30th July 2008.

CSCI found this care home to be providing an Adequate service.

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 12/07/07

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 13/11/2008.

CARE HOMES FOR OLDER PEOPLE The Salvation Army Holt House Headlands Drive Prestwich Manchester M25 9YF Lead Inspector Mike Murphy Unannounced Inspection 30th July 2008 09:00 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.V368201.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.V368201.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) Salvation Army Manager post vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places The Salvation Army DS0000008477.V368201.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. 12th July 2007 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 £374.95 to £515.42per week. (Information supplied by the provider). The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection which included a site visit that the home did not know was going to take place was carried out over an eight hour period on the 30th of July 2008. The process of inspection included observing what went on in the home, talking to residents, relatives, staff, the acting home manager, looking round the home, and examining some important records. Before the inspection, we also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home sees the service they provide the same way that we see the service. We felt this form could have been completed in more detail. This was discussed with the acting manager at the time of inspection. What the service does well: What has improved since the last inspection? What they could do better: Concern was expressed by some residents and relatives that at times either there was not enough staff on duty (or the home were relying on agency staff) and the outcome of this on resident’s was the quality of the support they received was not of the usual standard. Staffing provision should be reviewed – including consultation with residents and their relatives. A programme of The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 6 staff training needs to be developed to identify staff training needs and the views of residents should be sought to establish how satisfied they are with the care and support they are provided with. 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.V368201.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.V368201.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): 3 Standard 6 was not inspected as the home does not provide intermediate care Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have their care and support needs properly assessed before being admitted to the home. EVIDENCE: Before residents are admitted to the home a principle care worker (accompanied by a care worker) carries out an assessment of the prospective resident’s care and support needs. The assessment includes the involvement of the resident, their relatives and relevant health (such as doctors) and social care professionals (such as social workers). The reason for the assessment is to help the prospective resident (and their relatives) in deciding how suitable living at the home would be and enable the person doing the assessment to The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 9 judge if the home will be able to meet the resident’s care and support needs properly. 3 (recently admitted) residents pre-admission assessments were inspected. The records identified that pre-admission assessments had been carried out by the home and were supplemented by assessments conducted by Social/health Services professionals. The Salvation Army DS0000008477.V368201.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 and10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents were being appropriately met. EVIDENCE: The care records of three residents were inspected. The way care records are organised and recorded has significantly improved since the last inspection. Care plans addressed the health and personal care needs of residents in a clear, detailed, well-organised way and were evaluated at least monthly. Risk assessments, that aim to protect resident’s health, welfare and safety are also recorded in respect of residents skin (assessing the risk of pressure sores), mobility (including the risk of potential falls and fractures), nutrition, (including regular weight monitoring) were generally assessed monthly. However it was noted the assessments recorded in respect of skin integrity were not dated and had not been formally evaluated. The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 11 All residents are registered with a local GP and all were able to access dieticians, opticians, chiropodists, and dentists, district nurses and other specialist services as individual residents needed. Pre-inspection surveys completed by relatives and discussion with relatives on the day of inspection indicated that they are kept informed of any changes in their relative’s health. The practices for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and in the main safe. Medication training had been provided to all staff involved in supporting residents with their medication needs. Discussion with residents and staff (and responses in Pre-inspection surveys completed by residents and relatives) revealed that residents were treated with respect and that their right to privacy was upheld. Comments (made on the day of inspection and in completed pre-inspection survey forms) included; ‘I am very happy with home and staff’, ‘staff are kind and caring’, ‘this is a nice home and my relative is very settled and cared for well’, ‘I am well looked after here’. However the perception was expressed by some residents and relatives that at times either there was not enough staff on duty (or the home were relying on agency staff) and the outcome of this on resident’s was the quality of the support they received was not of the usual standard. This issue is addressed again in the staffing section of this report. On the day of inspection staff were observed to talk to residents positively and show them respect, protect their dignity and assist them properly throughout the day. Residents appeared to be well cared for and content in their environment. The Salvation Army DS0000008477.V368201.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. Residents are enabled to make choices in their daily life and there was a general satisfaction with the meals provided. EVIDENCE: The arrangements, for providing social and leisure activities were being reviewed at the time of this inspection. The acting home manager was in the process of recruiting an activities organiser to expand the exiting leisure and activities programme. The current programme of activities was prominently displayed in the home at the time of this inspection. Activities included singing, board games, music and movement, listening to music, entertainers and singers, a weekly outing to an over sixties group at Eccles and health and beauty sessions. Residents generally expressed their satisfaction with the activities available but some said staff are hard pressed at times to follow the programme due to their other commitments. Discussion with residents and relatives (and observations made on the day of inspection) indicate that the routines of daily life in the home are as reasonable The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 13 as they can be in a home setting. Residents said that they are able to choose what time they get up and go to bed, and feel that staff inform and consult them about the care and support they need (this was supported from the comments made by relatives of residents in pre-inspection surveys and in person to us at the time of inspection). This is very important in enabling residents to control their daily life as much as possible. Residents wishing to maintain their religious links are actively encouraged to do so. A prayer meeting is held daily in the home for those who wish to attend. The home has an open visiting policy. There are no restrictions on the time people visit. The only time restrictions would be imposed is when requested by residents. Relatives spoken to during the inspection said they were always made welcome at the home and were able to see their relatives in the privacy of their own room or in a quieter area of the home. Residents spoken to said they were satisfied with care and support provided and organisation of life at the home. Observation of care practice and information in care plans indicated residents are encouraged to make choices. For example in respect to where they spend their day. While some residents chose to sit in the lounge a number were observed to spend their time in their own rooms. Meals are cooked in the home’s kitchen. Menus are varied and balanced and provide choice. Meals are served in a spacious dining room. This is an appropriately furnished room that provides a comfortable and pleasant area for residents to have their meals. Residents’ meal times are as reasonable and as flexible as they can be in a home setting. Discussion with residents and relatives indicated satisfaction with the meals provided. The Salvation Army DS0000008477.V368201.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 adequate. This judgement has been made using available evidence including a visit to this service. Appropriate arrangements were in place to ensure residents are safe and their concerns can be addressed. However safeguarding training for management and staff needs to be extended. EVIDENCE: The complaints procedure was prominently displayed in the home and included details of how to contact the CSCI if it was felt necessary by the complainant. Residents and relatives spoken to on the day of inspection (and in responses contained within pre-inspection surveys) said issues brought to the manager’s attention are always responded to quickly and properly. The acting manager keeps a complaint record – there were no complaints recorded since the last inspection. Policies and practices (including a robust staff recruitment process) aimed at safeguarding residents from abuse were in place. Also Bury’s inter agency protection procedure is held on site. Most staff have been provided with safeguarding training. However arrangements should be made to ensure all staff (particularly the acting home manager and newly recruited staff) are provided with such training. This is essential to ensure residents are protected from abuse as much as possible. The Salvation Army DS0000008477.V368201.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): 19,20,21,24 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 provides a clean, pleasant, comfortable and suitably adapted environment for residents. EVIDENCE: A tour of the premises revealed the home was very clean and free of malodour throughout at the time of this inspection. Discussion with residents and visitors revealed that this is always the case. The main lounges and dining room (and those in each unit of the home) provide spacious, appropriate, comfortable and warm communal areas for residents. The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 16 WC and bath/shower rooms were suitably and appropriately equipped and adapted to meet the health and safety needs of residents. Seven bedrooms were inspected on this 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. Suitable measures were in place to minimise the spread of infection – including suitable 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.V368201.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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents felt they were cared for appropriately concerns were expressed about staffing levels. Arrangements need to be made to update staff training in mandatory topics to ensure that residents are supported and protected appropriately. EVIDENCE: Generally residents were of the view that staff at the home were meeting their care and support needs appropriately. However some residents and relatives have raised some concerns that (in their view) at times (both day and night) there was not enough staff on duty (or the home were relying on agency staff) and the outcome of this for resident’s was the quality of the support they received was not of the usual standard. The view is that this is unacceptable although those staff on duty do their best to cope. These concerns were discussed at the time of the inspection with the acting manager and her manager. We understand staffing provision is being reviewed at the home. The provision of staff at the home should be determined not merely by the numbers of residents living at the home but by their levels of dependency and other factors such as the layout of the building. The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 18 The home continues to make progress in the provision of NVQ 2 and 3 training. The acting manager was in the process of reviewing training provision and how this is recorded. She has identified that there is a need to develop a training programme to ensure all staff receive appropriate induction and ongoing training in mandatory topics (particularly newly recruited staff). This is important to ensure that residents are supported and protected appropriately by staff. 3 staff recruitment files were inspected on this occasion. They contained evidence of CRB checks (including POVA first checks), 2 written references, criminal convictions declarations, proof of identity (2 files included a photograph, 1 did not) and completed application forms – these included a detailed work history and a declaration relating to the prospective employees health status. The Salvation Army DS0000008477.V368201.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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home is being run adequately it does not have a registered manager in post. This is a legal requirement and needs to addressed. EVIDENCE: The home has not had a registered manager since September 2007. It is a requirement of The Care Standards Act (2000) that care homes have a manger registered with the CSCI. The acting manager (previously the home administrator) has been fulfilling her current role since May 2008. The acting manager informed us that she intends to commence the NVQ 4 qualification in care/management in the near future. The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 20 Discussion with residents, their relatives, and staff revealed that the acting manager adopts an approach that enables issues to be easily discussed with her and that emphasis is placed on operating the home in the best interests of the residents. 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 acting manager informed us that the home is due to canvass the views of residents and relatives in respect of how satisfied they are with the quality of the service provided, as this has not been done for some time. It is important such views are sought as it enables the home to identify concerns (such as those relating to staffing provision identified in this report) and enables the home to address the issues raised. The health, safety and welfare of residents and others are promoted and protected. Fire safety training is regularly provided. An inspection by the local fire safety officer had been recently conducted at the home. We have been informed that work was in progress to ensure the requirements and recommendations made during that visit were complied with. The premises were secure at the time of this inspection. The passenger lifts that enables residents and others to access all areas of the home have been serviced as has all hoisting equipment used in the home. Significant events in the home including accidents and illness are recorded and reported (as required legally) to the CSCI. Information supplied by the home indicates that electrical, gas, water and equipment generally in the home are inspected/serviced at appropriate intervals. The Salvation Army DS0000008477.V368201.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 The Salvation Army DS0000008477.V368201.R01.S.doc Version 5.2 Page 22 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 OP27 Regulation 18(1)(a) (b) Requirement That in response to concerns raised during the inspection staffing levels at the home are reviewed. And that the CSCI is informed in writing details of the outcome of that review. That a recent photograph of all staff working at the home is kept (as part of the proof of identity documentation). That the CSCI is informed in writing what arrangements have been made to ensure all staff employed at the home receive induction training and training (including updates) in safeguarding, moving and handling, fire safety, first aid and other relevant topics to ensure residents are appropriately supported by staff. That it is confirmed to the CSCI in writing that the requirements/recommendations contained in the local fire safety officer’s report (dated the 26/6/08) have been complied with. That the CSCI is informed in DS0000008477.V368201.R01.S.doc Timescale for action 30/09/08 2. OP29 19 (schedule 2) 13(4)(5) (6) 18 (1) c 30/09/08 3. OP30 30/09/08 4. OP38 23(4) 30/09/08 5. OP31 Care 30/09/08 Page 23 The Salvation Army Version 5.2 Standards Act 2000 Section 11(1) writing what action is being taken to ensure that the legal requirement to have a registered manager is complied with. 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. 3. Refer to Standard OP9 OP8 OP8 Good Practice Recommendations 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. If a resident declines to be weighed as part of the regular assessment of their nutritional status this should be recorded. That all skin integrity risk assessments in residents care records should be dated and formally evaluated at least monthly. The Salvation Army DS0000008477.V368201.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.V368201.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. 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!