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Inspection on 01/08/07 for Holyport Lodge Nursing Home

Also see our care home review for Holyport Lodge Nursing Home for more information

This inspection was carried out on 1st August 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Holyport Lodge offers a warm, comfortable and homely environment for the residents` who live there, and ensures the residents` individual needs are reviewed regularly and detailed within their personal plan of care. Staff treat residents` with dignity and respect, and residents` have an opportunity to have their say and be listened to from customer surveys and resident meetings. As quoted by a resident couple "we visited four homes and found this to be the best". The manager follows a recruitment procedure that ensures the safety of the residents`, and residents` needs are met by a trained and competent staff team. Residents` say they enjoy the food provided from a 24 hour menu that offers fresh fruit and vegetables, and homemade cooking. The home has a programme of social and recreational activities that residents` say they enjoy, and say they can choose whether to participate or not.

What has improved since the last inspection?

The home has improved staff training and systems in place to ensure the safe administration of residents` medication. A local pharmacist carries out annual inspections, and the home acts on recommendations made.Staff have attended Safe Guarding Adults Training, and are aware of multiagency procedures in place to ensure residents` are protected from abuse. The home now uses limited agency staff following successful recruitment of permanent staff.

What the care home could do better:

Some areas in the home are in need of refurbishment; however plans are in place for a major refurbishment of the home, which is due to commence September 2007. Emergency call bells are to be replaced within the refurbishment plan, but in the interim the manager must ensure staff respond to the residents` call bell in a timely fashion, to ensure the safety of the residents` and ensure their needs are met.

CARE HOMES FOR OLDER PEOPLE Holyport Lodge Nursing Home Holyport Maidenhead Berkshire SL6 2JA Lead Inspector Yvonne Souden Unannounced Inspection 1st August 2007 10:10 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 Holyport Lodge Nursing Home DS0000010993.V347564.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. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holyport Lodge Nursing Home Address Holyport Maidenhead Berkshire SL6 2JA 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) 01628 781138 01628 781707 saylem@bupa.com www.bupa.com BUPA Care Homes (BNH) Limited Mrs Marilyn Sayle Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (4) of places Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Adults with a physical disability will not be admitted below the age of 55. 18th May 2006 Date of last inspection Brief Description of the Service: Holyport Lodge provides residential/nursing care and accommodation for 45 older people. The registered provider is BUPA Care Homes (BNH) Limited. The home is an elegant, Edwardian/Colonial style house with attractively landscaped gardens, that add to the ambiance of the home. There are twentyseven single rooms and 9 double rooms over three floors, that can be accessed by a lift, most rooms have en-suite facilities, and those that don’t have a wash hand basin; double rooms are for kin share only. The home is situated on the edge of the Village Green in Holyport, close to the towns of Maidenhead and Windsor. Holyport Lodge has an information pack available on application to the home. Email saylem@bupa.com Information CSCI received 01/08/07 confirms that weekly fees start from £860 to £1,700. Additional charges are made for, hairdressing; newspapers; chiropody, manicurist and toiletries. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information gathered to support this report includes inspection records, documentation received from the home, and a 7.5-hour site visit to the home. The site visit enabled the inspector to observe care practice within the home and hear the views of the service from residents, staff and management. The site visit also gave the inspector an opportunity to view further documentation, and view the care plans of 4 residents. From the evidence seen by the Inspector and comments received, the Inspector considers that the home would be able to provide a service to meet the needs of individuals of various religion, race, or culture. The home follows the organisation’s policy and guidelines to manage issues relating to equality and diversity. What the service does well: What has improved since the last inspection? The home has improved staff training and systems in place to ensure the safe administration of residents’ medication. A local pharmacist carries out annual inspections, and the home acts on recommendations made. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 6 Staff have attended Safe Guarding Adults Training, and are aware of multiagency procedures in place to ensure residents’ are protected from abuse. The home now uses limited agency staff following successful recruitment of permanent staff. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holyport Lodge Nursing Home DS0000010993.V347564.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 Holyport Lodge Nursing Home DS0000010993.V347564.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, 3 and 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Holyport Lodge enables prospective service users’ and their representative to make an informed choice when considering the home as their new home. Service users’ care needs are assessed prior to a placement offer. The home does not provide intermediate care. EVIDENCE: On entering the home information is available on the range of facilities and services offered, which includes a most recent CSCI inspection report and Statement of Purpose. Holyport Lodge ensures prospective service users’ receive a detailed information pack about the services and fees charged. In April 2007 the home introduced a new format of assessment and care planning as developed by BUPA, known within the organisation as ‘QUEST’. The inspector viewed the needs assessments of four recently admitted service Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 9 users’. The needs assessments were user friendly enabling the reader to quickly identify the individual needs of the service user, and had a scoring system that deterred the level of need, and whether the identified need, for example communication, was to be added to the service user’s personal plan of care. Service users’ files viewed demonstrate that the home works closely with external health and social care professionals within the assessment and review of their needs. As quoted by a service user “my son gave them the information they needed prior to me moving in”. Holyport Lodge Nursing Home DS0000010993.V347564.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 good. This judgement has been made using available evidence including a visit to this service. The home works closely with Health and Social care services to ensure service users’ health and social care needs are met with dignity and respect, but this could be jeopardised by a slow response time to the service users’ emergency call bell. EVIDENCE: Care plans viewed gave clear information on how to support and meet the individual needs of the service user and minimise identified risk. Service users’ and/or their representatives are encouraged to be involved in care planning, and their signatures are obtained in support of the plan, with review dates set. It was evident that information gathered by management and staff to support individual care plans, include the initial needs assessment, a map of the service user’s life (detailed information about the service user’s childhood memories, relatives, work history, hobbies and interests), and risk assessments that include, nutritional screening, pressure care, manual handling and risk of falls. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 11 Records identify that service users have access to external health and social care services; the inspector observed that a service user had attended a hospital appointment on the day of the site visit, and observed external health care professionals visit service users’ within the home. The inspector observed morning staff pass vital information to the afternoon staff at their handover meeting, thus ensuring all staff were aware of any service users’ changing health care needs. The home has a contract for the disposal of drugs and sharps and complies with policies and procedures for the control, storage, disposal, recording and administration of medication. The Inspector observed only trained staff administer service users’ medication from a monitored dosage system, and observed that medication in stock match records kept. Records identify that the providing pharmacist carried out an audit of the home’s medication 12/07/06, recommendations had been made by the pharmacist that have been met by the home. Staff spoke of medication training received, and this was further evidenced from staff supervision and training records viewed. The inspector observed staff treat service users’ with dignity and respect, staff knocked on service users’ doors before entering, and responded to service users’ requests for assistance in a caring and pleasant manner. As quoted by service users’, “by in large the staff are perfect, and the foreign staff are exceptionally good”, “very good here, can’t complain, staff very caring”. Call bells do not provide the service expected by the service users’, as quoted “the bell system, they don’t always come, as busy with other patients”, Call bell won’t work”. Visitors also spoke of frequently having to wait twenty minutes before the door is answered, as quoted, “often a long time waiting, particularly at weekends when they don’t have a receptionist ”. The manager confirmed that a new call bell system is planned, and will be installed prior to the refurbishment of the home, scheduled to commence September 2007. In the meantime the manager confirmed that she would look at ways of improving staff response time whist waiting for the new system to be installed. Holyport Lodge Nursing Home DS0000010993.V347564.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 excellent. This judgement has been made using available evidence including a visit to this service. Activity plans support the diverse needs of the service users. Service users enjoy choice and are involved in menu planning. Service users are enabled to maintain links with family and friends. EVIDENCE: Service users’ said they were happy with the support they receive to participate in activities arranged by the home, and confirmed that there is a range of activities to choose from, for example, quizzes, communal exercise with the physiotherapist, arts and crafts, and organised trips within the local community. As quoted by a service user “activities, very good, yesterday went out on to the patio, we had quizzes”. The home has two part-time activity organisers who on the day of the site visit were encouraging service users to participate in a fashion show; activity staff modelled T-shirts designed by the service users’, as part of a BUPA ‘Themed Cruise of the Mediterranean’. The inspector observed a group of service users take part in Communion, and was informed by the manager that the local Church of England and Catholic Church hold frequent services within the home. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 13 The home’s menu plan is displayed in the dining room and ensures service users’ are given choice; records of the service users’ choice are kept, and service users’ said they were mostly satisfied with the meals provided. As quoted by service users’, “meals boring, because I am partly vegetarian, they do try, I think the chef needs to look at what is available, I miss watercress”, “meals very good, plain and wholesome, just what I like” and “meals, good choice, what you ask for they give you”. The home has recently introduced the BUPA night bite menu to ensure service users have a menu choice 24 hours a day. Information gathered within the service users’ personal plan, and information within the homes diet directory/fact sheets, would equip the home to meet the needs of service users’ from various religious and cultural backgrounds for example Chinese, Islamic, Jewish, Hindu and Sikh. The inspector spoke to visitors who said the home is always welcoming and that they are able to visit at any time of the day, as quoted by a visitor “everyone friendly, staff are very nice”, and by a service user “when my son visits, we sit in the garden”. Holyport Lodge Nursing Home DS0000010993.V347564.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaint procedure is readily available to service users’ and their representatives, and service users’ are safeguarded from abuse. EVIDENCE: No complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. Service users’ and their representatives have a copy of the home’s complaint procedure, and the home has responded appropriately to complaints made. Discussions with staff identify that they are aware and have knowledge of multi-agency policy and procedures to safeguard service users’, and are aware of the home’s whistle blowing policy. Staff spoke of ‘Safeguarding Adults Training’ received, and this was further evidenced from records viewed. Holyport Lodge Nursing Home DS0000010993.V347564.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable, clean and safe environment. EVIDENCE: A major refurbishment of the home is planned, and is due to commence September 2007. The manager confirmed that a new call bell system would be fitted prior to commencement of the refurbishment, and that risk assessments would be completed to ensure minimum risk and disturbance to the service users’. Holyport Lodge has three floors accessible by stairs or by a lift. Each floor was observed to provide a warm, comfortable, homely and clean environment, and service users’ have personalised their rooms. The home has comprehensive policies and procedures that include control of infection and handling clinical waste. Staff have attended infection control training, and were observed to use protective clothing. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 16 Fire records viewed show that weekly checks of fire equipment are maintained, and discussions with staff and records viewed confirm that staff attend regular fire safety training. Holyport Lodge Nursing Home DS0000010993.V347564.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. Holyport Lodge has a staff team that are competent, trained and sufficient in numbers to meet the health and social care needs of the service users’. EVIDENCE: It was evident from the provision of care observed at the site visit that staff were able to meet the personal care needs of the service users in an unhurried and attentive manner. The home reports that agency staff covered 123 shifts between March and June 2007; agency staff was used on the day of the site visit due to staff sickness, but there was evidence to demonstrate that the home has recently completed a successful recruitment drive and now has a full compliment of permanent staff. The home has policies on Equal Opportunities, Diversity, Anti-oppressive practice, and policies on Recruitment and Employment. Staff records viewed identify that recruitment procedures are followed; references and security checks are obtained on prospective staff prior to an employment offer. A full programme of external and internal mandatory and specialist staff training is in place. 33 of care staff has a National Vocational Qualification in care, and new staff spoke of their induction. Staff said that they receive regular supervision and support from management; this was further evidenced from records viewed. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 18 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 excellent. This judgement has been made using available evidence including a visit to this service. The home is managed by a competent and qualified manager whose leadership and management skills ensures service users’ needs are met in a relaxed and safe environment. EVIDENCE: The manager continually updates her knowledge and skill from courses attended and has managed Holyport Lodge for twelve years. Staff, service users’ and visitors were complementary about the manager and confirmed that she operates an open door policy. Records identify that annual, bi-monthly and monthly audits are undertaken, and that the home undertakes customer satisfaction surveys to ensure service users’ have their say. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 19 There was a positive and relaxed friendly atmosphere as the inspector walked around the home, and records identify that regular staff and resident/relative meetings take place. The provider and manager of the home do not act as appointee for handling financial affairs of the service users’. Service Users’ can choose to have a small amount of money held in safe keeping by the home; systems are in place to safeguard monies held. It was evident throughout the home that the Health and Safety of service users’, staff and visitors is paramount. The home has policies and procedures on safe working practice and staff receive regular training within Health & Safety, Fire Prevention, Moving and Handling, COSHH and Food Hygiene. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 20 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 4 X 3 X 3 3 X 3 Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 21 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 OP10 Regulation Requirement Timescale for action 02/08/07 13. (4) (c) The manager must ensure staff responds to the service users’ call bell within appropriate and safe timescales. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations On commencement of the refurbishment programme the manager should inform the Commission for Social Care Inspection, and forward a copy of their risk assessment, which would demonstrate systems in place to minimise risk to the service users’, and minimise disturbance within their daily life. Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Holyport Lodge Nursing Home DS0000010993.V347564.R01.S.doc Version 5.2 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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