Inspection on 05/06/06 for Holt House - The Salvation Army

This inspection was carried out on 5th June 2006.

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 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 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 Key Unannounced Inspection 5th May 2006 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.V288795.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.V288795.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.V288795.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. 1Oth February 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. Holt House is owned by the Salvation Army. The fees at the time of inspection were £512.00 per week. (Information supplied by the provider). The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of seven hours on the 5th of May 2006. The inspector spent time talking privately to residents, a number of relatives, and the manager and staff. All the lounge and dining areas were inspected as were a number of resident’s bedrooms. Care records and other records that are kept in relation to residents were also inspected. Residents appeared to be well cared for and content. The home was being managed appropriately and appropriately staffed to meet residents needs. What the service does well: What has improved since the last inspection? What they could do better: Whilst improvements have been noted in residents care records some issues relating to care plans and risk assessments were identified during the inspection. These have been discussed in detail with the manager and are featured in the body and requirements sections of this report. The home also needs to supply the inspector with copies of an up to date 5 yearly electrical safety inspection certificate and an up to date gas safety certificate. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 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 Salvation Army DS0000008477.V288795.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.V288795.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): 1, 2, 3,4,5. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are provided with the information they need to make an informed choice about where to live and the views of resident’s are central to the process of admission to the home. 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 spoken to were aware of this document (as were the relatives spoken to) and that a copy was in their room. A written contract is provided to all residents admitted to the home that details the terms and conditions of occupancy. All potential residents have their needs assessed prior to admission by a senior member of the care team. This is to ensure that the home is able to meet the potential resident’s needs appropriately. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 9 Discussions with residents, relatives, staff and the manager indicated that the whole admission procedure is aimed at ensuring resident’s admission to the home is monitored closely and that the resident’s experience is as less stressful as possible. Comments made to the inspector included ‘ I felt that my opinions were important when deciding if I should come here or not’, ‘They came to see me at home and then I was able to visit the home a couple of times before I came in’, ‘my dad has been well looked after since coming to Holt House and his placement was reviewed after about 6 weeks. Also as a family we have been consulted at all times’. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Whilst the health and personal care residents at the home receive is appropriate and is meeting the expectations of residents and their relatives some issues relating to the completion of care records were identified. EVIDENCE: The care records of 5 resident’s were inspected in detail. These contained assessments of need, care plans, risk assessments, and daily statements. Whilst some of these records were detailed and have improved since the last inspection and appropriate some were not. In particular all care plans should contain details of the specific actions staff need to take to address a particular identified problem. Care plans should also be formally evaluated at least monthly. Risk assessments for moving and handling and nutrition (including weight monitoring and the risk of pressure sores) are completed. However it is strongly recommended that these be formally evaluated monthly. It is also recommended that the risk of pressure sores should form a separate risk The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 11 assessment. The inspector understands that the home is intending to introduce new care record documentation that will deal with the issues raised above. Discussion with residents indicated that they were satisfied with the care they receive and that they are able to access health and social care services as their individual needs dictate. All residents are registered with a local GP and it was evident that all were assisted in accessing optical, chiropody, dental, district nurses and other specialist services as they required. Relatives were of the view that they were kept informed of all significant changes in their relation’s condition. The procedures for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate. 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 been completed appropriately. Residents who require insulin injections receive these from the district nurses who visit twice daily to provide this service when necessary. Discussion with residents revealed that they felt they were treated with respect and that their right to privacy was upheld. Comments made included; ‘the girls always knock on my door before they come in’, ‘I was asked what I wanted to be called when I first came to the home’, ‘the staff make sure you don’t feel you are a nuisance’, ‘the doctor sees me in my own room when he comes’. Discussion with staff and relatives indicate that those residents who are coming to the end of their lives are treated and cared for with sensitivity and respect. Discussion with the manager revealed that she is seeking some further training for staff in this important area of care. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were of the view that they are supported by staff to engage in social activities and are able to retain the ability to make personal choices. There was a general satisfaction with meals provision at the home. EVIDENCE: A prominently displayed activities programme was in place that reflected the provision of varied activities daily, occasional entertainers coming to the home and trips out. Residents identified the things they enjoyed and felt they were enabled to participate or not as they chose to do. Residents are consulted at residents meetings about the activities programme. And residents are also of the view that the routines of daily life were as reasonable as possible in a communal living setting – it was evident on the day of inspection a significant number of service users had chosen to stay in bed ‘late’. 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 are encouraged to maintain contact with local community – e.g. local churches, over 60s club. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 13 Residents indicated that they are actively encouraged and enabled to retain as much personal autonomy and make personal choices in their daily lives at the home – many have brought items of furniture to further personalise their bedrooms. 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 and sampled on the day of inspection. This was a hot and substantial meal and staff assisted and served residents their meals appropriately. Residents indicated that they were happy with their food provision – stated that if they did not like what was on the menu on a particular day a reasonable alternative was provided – and they felt comfortable enough to ask for this. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents and relatives spoken to said they felt comfortable enough to make a complaint if they felt the need and knew how to do so. 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: The complaints procedure was prominently displayed and also is available in the ‘Service users guide’ that is provided for resident’s information. Residents spoken to expressed the view that any concerns/worries they raise are responded to swiftly and rarely turn into formal complaints. A complaints log/incident log is maintained. There were no complaints logged since the last inspection (February 2006). 1 incident concerning money missing from a resident’s purse was logged – this had been appropriately reported to the police and the resident’s family. Holt House has an abuse policy for elderly persons. In the ‘Handbook of Employment’, which all staff access, 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 The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 15 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. Discussion with the manager revealed that she was looking at how to extend and update staff training in this important area of protection. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 16 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): 19,20,21,22,24,25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are clearly happy with the standard of the home’s environment and the comfort it provides. EVIDENCE: The home is well maintained and decorated to a high standard. Communal lounge/dining areas were comfortably and appropriately furnished and residents are also able to access substantial well maintained garden areas. All bedrooms benefit from an en-suite WC and washbasin. Appropriate numbers of bathrooms that are suitably equipped and adapted are available to residents and a passenger lift ensures resident’s can access all areas of the home. Some 8 bedrooms were inspected on this occasion. These were clean, well decorated and appropriately equipped and furnished. All bedrooms seen were highly personalised. Residents spoken to were very pleased with their personal accommodation and many had brought in some items of their own furniture to personalise their rooms even more. The inspector was informed The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 17 that new gas central heating boilers were to be fitted after the date of this inspection. The inspector was also assured that suitable interim arrangements had been made for heating the home appropriately. The home was clean and free of malodour throughout on the day of inspection. Clearly it is important that the environment which resident’s live is pleasant and comfortable as well as ‘homely’ as possible. Discussion with residents indicated they were very satisfied with the homes environment. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 18 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): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Resident’s were of the view that staff were meeting their needs appropriately and staff are subject to an appropriate recruitment procedure that is consolidated by appropriate training when appointed. EVIDENCE: Inspection of staff rosters, discussion with residents, the manager and staff indicated that the day and night levels of staff provided were appropriate for the needs of the 25 residents living at the home at the time of this inspection. 50 of the care staff have obtained an NVQ2 qualification (or above) in care and a further 6 staff (of the 27 in total) are identified a seeking to obtain such qualifications at the time of this inspection. No Staff have been recruited since the last inspection in February 2006 The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager is experienced, has achieved the NVQ Level 4 and is a qualified NVQ Assessor. She is currently completing a course of study to achieve the Registered Managers Award. 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. The manager is, supported by a deputy manager, a team of senior carers and care staff. There is also full time administrative support and maintenance person. Catering and domestic personnel are supplied through a company contracted for these services. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 20 The manager and Responsible Individual are still developing a quality assurance system to measure the satisfaction of resident’s 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. Inspection of the systems for managing residents’ finances (personal allowances) showed that there are clear, secure and well organised accounting systems that are regularly audited. Discussion with the manager, staff and inspection of records maintained at the home indicated that staff are appropriately supervised by senior staff on a daily basis and formally assessed by a senior colleague on a suitable periodic basis. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 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 3 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 3 X 2 The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 22 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 OP33 Regulation 24 Timescale for action A quality improvement plan must 05/06/06 be produced and implemented. This is carried over from the last report (February 2006) that had a timescale of 05/06/06 All Care plans must detail the 31/07/06 care to be provided and be formally reviewed on at least a monthly basis. That it is confirmed in writing to 30/06/06 the CSCI that an up to date NIEIC standard 5 yearly inspection of the electrical installation at Holt House has been completed and that any issues identified have been addressed. That a copy of a current gas 30/06/06 safety certificate in respect of Holt House is forwarded to the CSCI. Requirement 2. OP7 15 3. OP38 13 4 OP38 13 The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 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 OP8 OP8 Good Practice Recommendations That all residents risk assessments are formally reviewed at least monthly That a separate risk assessment is developed in respect of resident’s risk of developing pressure sores. The Salvation Army DS0000008477.V288795.R01.S.doc Version 5.1 Page 24 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. 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