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Inspection on 06/12/05 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 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

The home provides a comfortable and welcoming atmosphere to friends, relatives and visitors. The reception area of the home is usually manned by a member of the administrative staff who will answer any queries or concerns from visitors and the residents. Residents spoken to during the inspection confirmed their satisfaction with the food provided on the menu selections. Special diets are accommodated and resident`s likes and dislikes are acknowledged by the Chef. A resident commented on how kind and caring she found the staff. The homes financial administrator will spend time explaining the terms ad conditions/contract to residents and family.

What has improved since the last inspection?

Care plan documentation was found to be more detailed and informative to individuals specific needs. Basic care plans were now put in place usually within seven days of admission. The homes gardens were seen to be tidy and well kept.

What the care home could do better:

Medication administration by the Registered Nurses must be accurate and reflect what has been given as well as signed for. Psychological care needs must be assessed and included in care plans as required at the inspection in October 2004. The home must ensure that efficient and effective recruitment checks are made for all prospective employees. References from prospective employees must be authenticated. This concern had also been raised at two previous inspections in 2004. This is a serious shortfall in the home`s procedures and compromises the safety and protection of the residents in the home.

CARE HOMES FOR OLDER PEOPLE Holyport Lodge Nursing Home Holyport Maidenhead Berkshire SL6 2JA Lead Inspector Susan Burton Unannounced Inspection 6th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 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.V271085.R01.S.doc Version 5.0 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 saylem@bupa.com BUPA Care Homes (BNH) Limited No. 2079932 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.V271085.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Adults with a physical disability will not be admitted below the age of 55. 17th May 2005 Date of last inspection Brief Description of the Service: Holyport Lodge is an elegant, homely Edwardian house, situated on the edge of the Village Green in Holyport, near Maidenhead in Berkshire. It is owned by BUPA and registered to provide care for up to 45 older people, or to those who have a physical disability, or to those who require convalescence.The home has been converted but retains many of its original features and character, including an impressive oak staircase and hand carved oak panelling. There are two lounges, (one of which is used as a quiet room) and a dining room. These areas provide a central meeting place where service users can get together to read, watch television or chat. The gardens are attractively landscaped, and add to the ambiance of the home. The village of Holyport is situated close to the towns of Maidenhead and Windsor. Central London is easily accessible. Much of the above information was taken from the homes Statement of Purpose. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection on Tuesday 6 December 2005, which commenced at 10:30 a.m and finished at 14.40 p.m The manager of the home was available by telephone only during the inspection as she was in attendance at another of the organisations homes. The deputy manager was on duty but was supporting the family of a resident who had died minutes before the inspection commenced, therefore this inspection focused on a limited number of standards. The inspector spent some time in the homes kitchens discussing nutrition and menu selections with the head Chef and second Chef. A number of care plans were reviewed following requirements made at the last inspection, the inspector also looked at the recruitment records of a prospective member of staff. The home had not ensured that the references supplied were authentic which is a concern that had been raised at two inspections in the previous year. What the service does well: What has improved since the last inspection? Care plan documentation was found to be more detailed and informative to individuals specific needs. Basic care plans were now put in place usually within seven days of admission. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 6 The homes gardens were seen to be tidy and well kept. 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. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 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.V271085.R01.S.doc Version 5.0 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): 2 The organisation has recently reviewed its terms and conditions/contract. EVIDENCE: The inspectors spent some time with the homes of financial administrator discussing how terms and conditions were discussed with the residents. The administrator will spend time ensuring the complexity of the terms and conditions are fully explained to the residents and their family. She will also try to ensure that an individuals independence is protected wherever possible when dealing with financial matters. The administrator appeared sensitive to the dilemmas of the residents when dealing with their finances. Where there are concerns for an individuals capacity to understand or consent she will ensure that the manager or deputy are aware of this and that family is involved. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 The residents health and personal care needs are set out in a comprehensive and individualised plan of care. The residents psychological health needs are not fully documented. The health and well being of the residents are compromised where medication administration procedures are not correctly followed. EVIDENCE: Following the last inspection great efforts had been made to improve the information and detail recorded in residents care plans. Four care plans were examined during the inspection, which were seen to have detailed assessments in regard to an individuals safe environment; communication needs, mobility and manual handling needs and included appropriate risk assessments. The information recorded was kept up to date and relevant to the individual residents health and welfare needs. All care plans were seen to be reviewed monthly. The care plans contained information on nutritional and dietary needs, assessment of skin integrity and tissue viability and falls risk assessments. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 10 The care plans did not contain specific assessments on how a resident psychological/emotional health was to be monitored and what preventative and restorative care was to be provided by the staff. This issue had been raised with the manager at the inspection that was undertaken in October 2004. From examination of the controlled drugs register and medication administration sheets it was found that a pain relieving drug had been signed for by one of the Registered Nurses but had not given, which is a serious error and compromised the comfort and well-being of the resident. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive a wholesome and appealing diet in comfortable surroundings. EVIDENCE: The inspector spent some time in the kitchen talking to the head Chef and the second Chef. The head Chef has been in post for six months and is a competent and experienced cook. The kitchen appeared small for two chefs who prepare and cook all the meals for staff and residents; they are also expected to clean the kitchen without assistance, which can be problematic when only one Chef is on duty. Both Chefs were enthusiastic and appeared to enjoy providing a wide range of meals appropriate to the needs of the residents. The inspector discussed the special diets that are provided and their presentation and was satisfied that both Chefs fully understood the necessary nutritional requirements and how important presentation was. The majority of the soups and cakes are homemade. The Chef has a list of individual residents likes and dislikes which he will we try to accommodate. The chef has a budget of £4.35 per person per day, which enables him to provide a range of choices from basic simple meals to more elaborate selections. Residents select their menu choices the day before; a change of mind on the day can usually be accommodated. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 12 Both Chefs need to update their food hygiene certificates. The inspector spent some time with a resident who has a special diet provided. The resident was asked for her views and opinions on the selection and quality of the food. She was able to say that she was more than happy with the selection that was made available for her and the quality of the food that was provided. The resident confirmed that both Chefs will on occasions come round and talk to the residents asking them for their views and opinions about the food, which is good practice. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The home keeps a record of the number of complaints made on a monthly basis, which is fed back to the organisation. Residents rights to participate in the political process are encouraged and upheld. Assistance is given with financial matters where appropriate. A requirement from the previous inspection that the monitoring of residents well being following an injury were to be documented appeared to have been actioned. EVIDENCE: In the absence of the Registered Manager the deputy manager assisted the inspector in reviewing the complaints made in the home since the last inspection. The homes monitoring procedure evidenced that since the inspection in May 2005 12 complaints had been made. The deputy manager was not able to produce the information specific to what each individual complaint was about. Without this information the inspector was not able to judge whether this was an unusually high number of complaints and concerns or whether it was that the organisation had a very effective and efficient complaints procedure that monitored very minor grumbles. This information should be available for inspection and will be followed up at the next visit. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 A requirement from the previous inspection that the home complied with the requirements made by the Royal Berkshire Fire and Rescue Service had not been provided in writing. The requirement to send a new fire risk assessment had been followed up, but did not confirm that this risk assessment met the fire officers standards. A residents comfort was compromised by the noise in her room from the laundry. EVIDENCE: The home is required to confirm in writing that the advice and guidance that was given by the Berkshire Fire and Rescue Service following their visit in May 2005 has been complied with or advise CSCI what action is being taken with appropriate timescales. Confirmation should also be sent that the homes fire risk assessment meets the Fire Officers standards and requirements. The inspector visited the bedroom of one resident to ask her for her views on the quality of life in the home and the service she receives. The discussion Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 15 was interrupted by the noise from the laundry next door. The washing machines sit on a concrete plinth, which vibrates and sends a low-pitched droning noise into the bedroom, which was most disturbing. The resident advised the inspector that on some occasions this happens late in the evening. The home should review the laundry arrangements and facilities to minimise the discomfort of the resident in this particular bedroom and consider using some noise prevention equipment. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29 The home is unlikely to achieve the recommended 50 of care staff with NVQ2 or above by the end of 2005. The homes recruitment procedures compromised the safety of the residents. EVIDENCE: The deputy manager advised the inspector that there were 22 care staff employed including bank staff but only 6 individuals had achieved NVQ 2. At the time of the inspection there were only 2 members of staff currently working towards achieving NVQ 2. The home needs to review the progress being made towards 50 of its care staff achieving NVQ above. The inspector examined the recruitment files of a prospective member of staff who appeared to have been chosen to work on the night shift. The references supplied were not authenticated and did not appear to be professional. These records did not evidence that full and satisfactory information had been supplied or sought. The concern was discussed and explained to the deputy manager. Requirements had been made at two previous inspections in 2004 that references supplied by prospective employees must be authenticated. The same issues were raised at this inspection and the inspector was concerned to see that staff were about to commence working in the home without thorough Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 17 checks being made, this is a serious shortfall in the homes procedures and compromises the safety and protection of the residents in the home. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected. EVIDENCE: Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 1 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13 (2) Requirement Medication administration is to be accurate and in line with NMC guidance to ensure the comfort and well being of the residents. The Registered Person ensures that references are authenticated and appropriate. This requirement has been made on previous inspections. The Registered Person ensures that care plans detail the psychological and emotional well being of residents and record how needs are to be met by staff. This requirement has been made on previous inspections. The home is to confirm in writing that the advice and guidance given by the Berkshire Fire and Rescue Service following their visit in May 2005 has been complied with or advise CSCI what action is being taken with appropriate timescales. Confirmation that the homes fire risk assessment meets the Fire Officers standards is to be sent. The home is to review the DS0000010993.V271085.R01.S.doc Timescale for action 06/01/06 2 OP29 19 (4) c 06/01/06 3 OP8 15 06/02/06 4 OP19 19 06/02/06 5 OP19 23 (1) 06/03/06 Page 21 Holyport Lodge Nursing Home Version 5.0 laundry equipment and facilities in regard to the noise levels in the bedroom next-door for the comfort of the resident in occupancy. 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 OP16 OP28 Good Practice Recommendations The homes complaints records should include details of investigation and any action taken and be available for inspection. The progress of NVQ training is to be reviewed. Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holyport Lodge Nursing Home DS0000010993.V271085.R01.S.doc Version 5.0 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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