Care Home: Hollycroft Nursing Home

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What the care home does well The registered manager responded to the previous inspection report with a number of improvements. Requirements and the majority of good practice recommendations issued at the last inspection visit were actioned. There were good relationships with the local health care services, providing support for people living at the home. A physiotherapist told us that the staff were knowledgeable about the people`s healthcare needs, were resourceful and always sought advice for any concerns. This demonstrated the good level of trust and professional respect between the home and primary care services. People were encouraged to treat the home as their own home and to be as independent as possible. People were encouraged to personalise their bedrooms with their possessions and furniture if they wished. We received positive comments from people living at the home which included, "I Can get up and go to bed when I want to"; "Food is very good"; and "the staff are very kind, friendly and helpful" People could make choices about their daily routines, activities and meals. They were encouraged and supported to take an active part in meetings and surveys at the home. There was good involvement in the running of the home and people had contributed their views about the activities, planned outings and food. People told us they enjoyed their meals, which looked appetising. There were good links with local churches and arrangements were in place for people to practice their faith. People knew how to raise concerns and make complaints and were confident these would be dealt with. The home had a relaxed, homely ambience and it was generally warm, very clean and comfortable. Comments from people and their relatives included, "I like staying here", "I am happy to return here for my short respite visits", and "when visiting, I see professional care and assistance in a clean environment" The staff were caring, committed, flexible, and well trained. The registered manager, nurses and staff kept themselves up to date with training to make sure people are cared for as well as possible. What has improved since the last inspection? Each person, and as appropriate, their relatives were involved in the plan of how their care was to be provided. Care plans were being improved to be more person centred, giving staff instructions how to care and support each person, though further improvements were needed. There was a new activities organiser, who was developing a wider range of activities and completing a `My Life Biography` for each person. There was an on going programme of redecoration and refurbishment, with improved lounge areas, dining facilities, lighting and bathing facilities. A new gardener had been employed and there were plans to grow fruit, vegetables and herbs, so that people could enjoy meals with home grown produce. Improvements had been made to staffing arrangements with increased numbers, skills and knowledge of staff to meet the needs of the people living at the home. The registered manager had undertaken some quality assurance audits so that shortcomings could be proactively recognised and actions taken to improve the service. What the care home could do better: Care plans need further development, so that they are person centred, include all assessed needs and show that each person and where appropriate their representative is involved and in agreement. Pressure relieving equipment must be maintained at the correct setting to be effective in preventing skin damage. Some aspects of medication practices needed further improvement to make medication administration as safe as possible. The redecoration and maintenance programme needs to be completed so that the standards of the premises are pleasant and safe for people using the service. All equipment, such as bedrails must be monitored and maintained to demonstrate compliance with legislation to safeguard the health and safety of all persons at the home. Key inspection report Care homes for older people Name: Address: Hollycroft Nursing Home 8-10 Redhill Stourbridge West Midlands DY8 1ND     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 2 1 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Hollycroft Nursing Home 8-10 Redhill Stourbridge West Midlands DY8 1ND 01384394341 01384375901 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Leyton Healthcare (No 7) Limited Name of registered manager (if applicable) Susan Scott Type of registration: Number of places registered: care home 37 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of users who can be accommodated is: 37 The registered person may provide the following category of service only: Care Home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places, 37 Dementia - Code DE, maximum number of places, 37 Physical disability - Code PD, maximum number of place, 37 Date of last inspection Brief description of the care home Hollycroft Nursing Home is owned by Leyton Healthcare (No.7) Limited. The home is a Victorian house, which has been adapted to provide accommodation for up to 37 older Care Homes for Older People Page 4 of 37 Over 65 0 37 0 37 0 37 1 9 0 1 2 0 0 9 Brief description of the care home people who may require nursing care. Six beds are purchased by Dudley Primary Care Trust (PCT) and are used for short respite stays for rehabilitation. The home is situated on Red Hill, close to the centre of Stourbridge. The home provides accommodation in 25 single and six shared bedrooms on two floors. Eleven of the single occupancy rooms offer en suite facilities, these consist of a toilet and hand basin. The home has a passenger lift for access to the first floor. There are three communal lounges and two dining areas. To the rear of the home there is a large enclosed garden. Access at the front of the home provides an area for off road car parking. People are advised to contact the home for up to date information about fees. There are additional variable charges for the services of a hairdresser, chiropodist and newspapers. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last Key Inspection took place on 14/01/09. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included discussions with the registered manager, deputy manager, area manager and staff on duty during the visit. We also talked to people living at the home, and made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the Commission. We looked at a number of records and documents. The acting manager submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to the inspection visit. Care Homes for Older People Page 6 of 37 We looked around the premises, including communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. Responses to CQC surveys have been included throughout the report. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? Each person, and as appropriate, their relatives were involved in the plan of how their care was to be provided. Care plans were being improved to be more person centred, giving staff instructions how to care and support each person, though further improvements were needed. There was a new activities organiser, who was developing a wider range of activities Care Homes for Older People Page 8 of 37 and completing a My Life Biography for each person. There was an on going programme of redecoration and refurbishment, with improved lounge areas, dining facilities, lighting and bathing facilities. A new gardener had been employed and there were plans to grow fruit, vegetables and herbs, so that people could enjoy meals with home grown produce. Improvements had been made to staffing arrangements with increased numbers, skills and knowledge of staff to meet the needs of the people living at the home. The registered manager had undertaken some quality assurance audits so that shortcomings could be proactively recognised and actions taken to improve the service. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an easy to read statement of purpose and service user guide, though the information about fees has been omitted. People living at the home had contracts terms and conditions of occupancy, which contained some ambiguous terms. This has the effect that people and their representatives do not have full information regarding their rights and entitlements, and how care will be provided. The home uses assessment tools so that each persons needs are assessed to ensure that their needs and preferences will be met. The home actively encourages introductory visits and people have the opportunity and time to make decisions, which are right for them. Evidence: The information contained in the homes AQAA (Annual Quality Assurance Assessment) about what it did well stated, We encourage visits to the Home prior to admission. A brochure is provided and a Welcome Pack is available to any service user Care Homes for Older People Page 11 of 37 Evidence: not able to visit prior to admission. We were able to verify the information in the AQAA and we saw that the home had an up to date statement of purpose and service user guide on display. We saw that these documents were provided in large print and could also be provided in alternative formats on request. The aims and objectives, admission criteria were clearly set out and information about the home was easy to read and understand. Unfortunately the updated service user guide had some information omitted notably about the range of fees and payment arrangements. Overall the information was useful for people to help them make decisions about their choice of home. The AQAA told us that there were planned improvements, To produce an improved and more informative brochure. This could also be accessed on our website. Involving the Home more in our community wherever possible. To continue with our open access approach to the Home and information. We looked at a sample of case files of people recently admitted to the home, which showed that each person was provided with a contract and statement of terms and conditions. This document contained some ambiguous statements about what was included in the fee, such as payments for staff escorts for health appointments outside the home. There was information about role and responsibility of the provider and the rights and obligations of the person living at the home. The home did not provided terms and conditions of residency for people using the short stay respite service, which would demonstrate good practice. From the information provided at the home we noted that there were people funded through Local Authorities, Local Primary Care Trust and a small number of people were funding the costs of their own care. Responses in discussions confirmed people felt they had the right information to make a choice about the home and had received a copy of their contract or terms and conditions for their stay at the home. There was evidence from examination of a sample of care records at the home and from discussions, which confirmed the good practices claimed in the homes AQAA. Such as pre admission assessments, which were conducted professionally and sensitively and had usually involved the family or representative of the person. However we saw two care files where assessments had not been signed. The preadmission assessment documentation was generally well completed with individual preferences such as rising, retiring, preferred activities, likes and dislikes. This meant that staff had good and accurate information about each persons needs and Care Homes for Older People Page 12 of 37 Evidence: preferences about how they wished their care to be provided. There were six short stay GP respite beds funded by the PCT. People we were able to speak with told us they enjoyed their time at the home and were happy to have regular short stays. People were also able to have good access to community services such as physiotherapy and occupational therapy to aid their rehabilitation. A healthcare professional spoke in glowing terms about the care, assistance and support people received from staff at the home and the positive outcomes where some people regained skills to allow them to return home. She gave us an example where someone considered not able to mobilise was able to walk again. Care Homes for Older People Page 13 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are care plans and risk assessments, which are adequate to identify peoples needs and provide staff with guidance. There are generally assurances that individual needs will be met for each person. The arrangements for administration of medication do not entirely ensure people receive their medicines as prescribed by their doctor, which may pose risks to their health and well being at times. People can feel assured that they will be treated with respect and their privacy and dignity will be maintained. Evidence: We looked at a sample of care records of people living at the home. The registered manager was developing and improving care records to be more person centred to meet each persons needs. We discussed where further development was required, for example choices regarding personal hygiene should be specific as to whether the person preferred to be bathed or showered, how often, at what time of day and what Care Homes for Older People Page 14 of 37 Evidence: type of toiletries the person liked to use. From records and discussions we saw that each persons health was monitored with appropriate action taken. There were health care assessments, and screening tools, such as falls assessments, tissue viability and the Malnutrition Universal Screening Tool (MUST), which were used to assess skin condition and weight. The moving and handling risk assessments gave score but did not record in detail what assistance was required for each transfer. Improvements should give staff guidance about what equipment should be used, such as slide sheets, named hoists and slings or walking aids. There were appropriate wound care regimes in place for people who had been admitted to the home with hospital acquired pressure ulcers. There were records of pressure relieving equipment in use but there were some inconsistencies. For example records for one person being nursed in bed indicated two different types of mattress were being used at the same time, Nimbus 3 and Alpha Xcell . We saw that the Alpha Xcell was in place, with a high pressure setting. The manager acknowledged that the setting would be too firm for the small, frail persons body weight. We recommended that the correct pressure for each person should be recorded as part of their care plan and should be monitored regularly. This is to make sure the equipment is used effectively to prevent skin damage. There were examples where significant changes had been referred to doctors and health care professionals, such as dieticians, for advice and support and appropriate reviews and monitoring. There were appropriate care plans to make sure people who required artificial feeding via naso-gastric tubes and PEG (Percutaneous Endoscopic Gastrostomy) tubes received their feeds as prescribed. People had good access to health care services to meet their assessed needs. We were told that people could choose their own GP within the limits of geographical borders. We saw that people, especially persons admitted into intermediate, GP respite beds, had access to community services such as physiotherapists, occupational therapists and speech and language therapists. We saw that people had access to opticians, dental and chiropody services where they had assessed needs for these services. A visiting physiotherapist told us that she felt staff were helpful and knowledgeable about peoples needs and she was very pleased with the care, support and rehabilitation arrangements for people to assist them to return home or move to a placement suited to their individual needs. Care Homes for Older People Page 15 of 37 Evidence: The home had a key worker system to provide individualised care and support. We were told that each person would have life history information, giving staff improved insight into personal preferences and activity choices. There were additional improvements needed such as care plans for people with dementia, which should be expanded to include all presenting symptoms. The care plan and records of oral care for someone who could not have oral foods or fluids needed to be improved. The person was being fed via a naso-gastric tube. There were no specific instructions as to how staff should maintain oral hygiene, though we were told that mouth swabs were being used. The instructions were that mouth care procedure should be performed at least two hourly but this was not demonstrated on the special care records. The persons mouth looked very dry; we were told this was because of mouth breathing due to a chronic chest condition. We looked at the homes systems to manage the medication. The home used a Monitored Dosage System (MDS) for people living at the home on a permanent basis. Medication for people at the home on a temporary basis had a variety of medication administration arrangements such as mediboxes, cassettes and original containers. We saw that the supplying pharmacy supported the home with advice related to medication issues at audit visits. We were told that medication was administered by the qualified nurses. Care assistants applied topical medication such as creams. The application of topical medications was not recorded on the MAR (Medication Administration Record) sheets. We recommended that a system should be devised for recording the application of creams and other topical applications. We saw that there was an oxygen cylinder stored on the premises and though there was signage on the door, this was not in an up to date format. New signage should be obtained where oxygen is stored in compliance with up to date guidance to show the inflammable gas storage. We noted that the room where medication was stored had exterior windows and we recommended that a risk assessment should be undertaken for the overall security of medication stored in the dedicated medicine room, with improved security measures put in place. The temperature of all medication storage was checked and recorded daily. The room temperatures were maintained within satisfactory limits, below 25 degrees centigrade. We saw records for the temperature of the refrigerator, which were within the recommended two to eight degrees C. However we recommended that a medication fridge thermometer, which recorded daily minimum and maximum temperatures over each 24 hours should be obtained, with records to show that the medication fridge temperature is maintained between 2 degrees C and 8 degrees C at Care Homes for Older People Page 16 of 37 Evidence: all times. We noted that Xalatan eye drops were stored in fridge. We discussed the manufacturers instructions with the manager. These stated the eye drops should be refrigerated prior to opening and stored at room temperature below 25 degrees C after opening. There was appropriate storage and records of Controlled Drugs; and we carried out random audits, which were accurate. We looked at the medication administration record (MAR) charts and overall found that they were documented with a signature for administration or a reason was recorded if medication was not given. For example, one person was prescribed an anticoagulant to thin the blood. This medication required blood checks to ensure the correct dose was prescribed, which could vary depending on the result. However there were no carried forward balances of this medication on the MAR chart and the records were difficult to audit. This meant that we could not see exactly how much medicine had been given to the person. There were also pain relief and antipsychotic medicines, which were prescribed as variable dosages, such as one or two tablets or 5 mls or 10 mls. The actual dosage administered was not always recorded, which made auditing difficult and posed potential risks that people may not receive their medication as precribed. We saw that the majority of the MAR charts were printed by the pharmacy and sometimes the MAR charts were handwritten by care home staff. We saw that the majority of the handwritten MAR charts were checked and signed by two staff for accuracy. We noted that people with PEGs or naso-gastric tubes had their medication crushed and administered via their tube. The registered manager told us that the hospital had supplied pill crushers to enable this procedure to be carried out. She acknowledged that there was no written protocol or procedure for staff guidance. The management must seek advice and devise a protocol for the administration of crushed medication via PEGs or naso-gastric tubes to include the dilution and flushes required. From our observations and in discussions it was evident that staff were aware of how to treat each person with respect and to consider their dignity when delivering personal care. Care Homes for Older People Page 17 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are planned and spontaneous activities available on a regular basis offering people ample opportunities to take part in socially stimulating events. People are enabled and encouraged to maintain good contact with family and friends. The dietary needs of each person are well catered for with a balanced and varied selection of foods that meets their preferences and nutritional needs. Evidence: The homes AQAA cited the following evidence of what had been improved over past 12 months, We have introduced a new and more pro-active Activities Co-ordinator and as a result of this there have been more organised planned activities with a greater variety. We have also introduced a Newsletter detailing the seasonal activities. We saw evidence for the accuracy of the claims made in the homes AQAA. We saw that staff listened to people living at the home and made considerable efforts to provide flexible daily living routines, which enabled people to enjoy a good quality of life according to their personal preferences. Care Homes for Older People Page 18 of 37 Evidence: We noted earlier in the report that the home has a key worker system, which enabled closer relationships between the people accommodated and staff, where likes, dislikes and needs were known in more detail and were met in a person centred way. We were shown examples of how the new activities organiser was completing a My Life Biography for each person, which should give staff valuable insight into each persons past life and improve the person centred aspect to their care. In addition to the activities organiser we saw that staff at the home took responsibility for collating the information gained from peoples preferences and planned activities, which each person could enjoy. We saw information displayed bringing peoples attention to community events and activities. It was understood and respected that some people preferred to spend their time in their own bedrooms, and they were supported with individual interests. During discussions there was evidence that staff knew and understood about peoples faith and where this was an important part of their life, they were supported attend services as and when they wished. We looked at a sample of peoples individual activities records, which were well completed, with refusals recorded. We received some comments from people who felt there could be even more time dedicated to activities and social stimulation, which we discussed with the registered manager during the inspection. The home has good involvement in the local community and we were told about a nativity play performed by local school children for people at the home. We were told about trips to the local town, Stourbridge and fund raising events, which were used to provide extras to the budget for residents activities. The programme of activities included games, quizzes, musical events, with country and western music a particular favourite; and pampering days especially for people nursed in bed. We saw people enjoying games of floor skittles during the inspection visit, and one person told us she would like George Clooney as a prize. There were monthly church services at the local church for anyone wishing to attend and we were told that two people regularly attended a Methodist church, where a relative was a lay preacher. There were also some people at the home who received visits from their own ministers. We saw evidence that family and friends were welcomed and people told us they knew Care Homes for Older People Page 19 of 37 Evidence: they could visit the home at any time. We were told that the management and staff team always made time to talk to visitors, offer refreshments and share information where this was appropriate. We noted that there were telephone numbers for independent advocacy groups displayed, which meant that people could contact external agencies for independent support as they wished. We saw that people were encouraged to bring in their personal possessions to personalise their room. We saw inventories of personal possessions on the sample of files examined, though these were not all up to date, signed and dated by the person or their representative and witnessed by the member of staff. We discussed nutrition with the staff and the manager. They were knowledgeable about each persons nutritional needs and we saw that a choice was always offered. There was regular use of the MUST (Malnutrition Universal Screening Tool) and BMI (Body Mass Index) screening. This made sure that any concerns about each persons weight were quickly identified with action taken to involve doctors and dieticians as needed. We saw that the monitoring arrangements also reflected the good hydration and nutrition at the home. We saw plenty of cool drinks available around the home and heard staff offering frequent warm drinks. Special diets such as diabetic and soft diets were provided. There was also added calorific value at mealtimes for people with poor appetite or at risk of weight loss. We discretely observed mealtimes and saw that staff were aware to the needs of people who found it difficult to eat and they offered sensitive assistance with feeding. They were aware of the importance of offering food at the persons pace, so that they were not hurried. A small number of people chose to have their meals at a different time, or in different locations, to allow them time and space to eat at their own pace. Improvements had been made with the dining rooms since the last inspection to make them look inviting. The meals appeared appetising, and meal times were protected to provide a sociable, enjoyable experience. We asked a sample of people about the food at meal times, and received generally very favourable comments, the food is very good and plentiful. One person told us that she preferred the option of homemade soup with bread, which she very much enjoyed. There were written menus for each meal, with choices, though there were no other formats for people unable to understand the written information. We recommended Care Homes for Older People Page 20 of 37 Evidence: that alternative formats for menus should be put in place to help people who could not read or understand written information to make realistic choices. Care Homes for Older People Page 21 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can generally feel assured that any concerns and complaints are listened to with action to investigate using systems to record findings and outcomes. There are arrangements in place to safeguard people living at the home. Evidence: We saw copies of the complaints procedure displayed in the home and included in the service user guide. The information telling people how they could raise concerns or complain had not been provided in alternative formats for people unable or read or understand the written information. Information in the Homes AQAA told us that the home had received two complaints in the past 12 months, which had been investigated and upheld by the provider within 28 days, with satisfactory resolutions implemented. The responses during the inspection and from surveys returned to us indicated that people were aware of how to raise concerns or use the homes complaints procedure. This demonstrated positive practice and the homes proactive response to peoples experiences and perceptions of the service. The homes AQAA told us, We have had more discussions with staff and relatives to make everyone aware of the complaints procedure. We also saw that Advocacy Information was readily available around the home. Care Homes for Older People Page 22 of 37 Evidence: We were told that there had not been any safeguarding alerts or referrals made by the home in the past 12 months. The home had policies and procedures to inform staff about abuse and responsibilities for reporting suspicions or incidents. Some of these needed to be reviewed and updated. We spoke to some staff who told us that they knew where they must report allegations or suspicions of abuse. There was a copy of the multi-agency Safeguard and Protect procedure for the protection of vulnerable adults at the home. We recommended that all staff should read and sign policies to demonstrate awareness of procedures to safeguard people at the home. Minor improvements should be made to the recruitment processes so that vulnerable people living at the home can feel assured that all staff are suitable care for them. Care Homes for Older People Page 23 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a generally warm and comfortable environment for people living there. There are systems in place for maintaining infection control. Evidence: This was a large Victorian building, adapted to provide nursing care for up to 37 older people. The size of the home meant that continual maintenance and repair work was needed to meet standards required. We had reported at the previous key inspection that improvements were needed to maintain the home to acceptable standards. The exterior of the premises needed attention to flaking paintwork and worn wooden window frames. There was a large car park, with marked bays at the frontage of the home. The large rear garden, had a large number of fruit trees, paved areas, garden furniture, a bird table and planters. The registered manager told us that a new gardener had been employed and there were plans to grow more produce so that people could enjoy more home grown ingredients in home cooked meals. Since the last key inspection the registered manager had put in place a maintenance and renewal plan and a reporting system for minor repairs, which required a reactive response. She told us that the organisation employed contractors to carry redecoration and we saw this taking place during the inspection visit. However there were parts of the home, which were still to be refurbished, looking tired and shabby, such as some paintwork in corridors and some bedrooms. Care Homes for Older People Page 24 of 37 Evidence: The homes AQAA cited the following improvements, which had been made to the environment, We have redecorated many areas of the home. We have also provided more quieter areas for those that wish to take advantage of this. We have also purchased new dining furniture. The AQAA told us about plans for improvement in the next 12 months, which were stated to be, We plan to improve flooring throughout the home and to continue our refurbishment plan for all bedrooms. We looked around the home and noted that since the last inspection the dining rooms had been renovated to be more attractive and inviting. The small dining room had been completely redecorated and refurbished with new tables and chairs and there were fresh flowers as table decorations and condiments on the tables. There were new large flat screen televisions and DVD players in each lounge. New blinds had also been provided, though the registered manager told us some people were not in favour and further discussions were taking place. She informed us that an option might be to dress the windows with curtain shams, so that the communal rooms looked more homely. New improved lighting was being installed in the corridor and communal lounges during the inspection visit. This considerably improved the lighting in these areas and people told us they liked the new lights. Whilst we were in the large lounge we noticed it not very warm. The registered manager explained that the radiators had been removed and new electric heaters had been installed but these were not on and reason was being investigated. We saw that all the people sitting in this area had been supplied with blankets and when we spoke to them, they told us they were warm enough. We looked at a sample of bedrooms with peoples permission where possible. Some were adequately furnished but needed renovation and redecoration, acknowledged by the registered manager. Others had been attractively redecorated and personalised according to individual preferences with family photographs, ornaments and small items of personal furniture. We saw that some people had beds with third party bedrails, which were loose and had excessive gaps, which could pose risks of entrapment or injury. One person also had an overlay pressure relieving mattress and the uncompressed height of mattress to the top of the bedrails was less than 100 mm, which did not conform to the Health and Safety Executive (HSE) permitted dimension of a minimum 220 mm. Other people had nursing profile beds with integral bedrails and pressure relieving mattresses in place, which meant that the height of the bedrails did not conform to HSE guidelines with potential risks to peoples safety. We discussed the need for extended height third party bedrails, improved risk assessments, regular documented checks and staff training to improve their knowledge and skills to make Care Homes for Older People Page 25 of 37 Evidence: checks and take remedial action where necessary. There were assisted bathing and toilet facilities close to bedrooms and communal areas throughout the home. The majority of these had been refurbished and redecorated. One toilet had a self cleaning, heated seat, plumbed into the mains, which we were told was a great success with the ladies. There large laundry was well equipped with commercial washers and tumble dryers and a rotary iron. The laundry service was generally well organised. There were supplies of disposable gloves and aprons readily available in the laundry. However we were not shown evidence that the home was using the Department of Health Essential Steps for Infection Control. The registered manager acknowledged that the laundry procedure and infection control guidance was not displayed in the laundry. We recommended that guidance should be easily available and on display so that staff are reminded to use effective infection control measures at all times. The kitchen was maintained in good order, and it was clean and tidy and well organised. We noted that appropriate food hygiene and safety measures were in place, with satisfactory records maintained. Care Homes for Older People Page 26 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff generally meet peoples needs and recruitment processes safeguard vulnerable people living at the home. There is a training programme in place to equip staff with skills to meet peoples needs. Evidence: The homes AQAA cited the following as evidence of what they do well, We have improved the number of staff who have trained to NVQ Level 3 and we have also have a good retention of staff. We were able to verify the good practices claimed from observations, discussions and examination of samples of records during this visit. We noted that there were 28 people accommodated, with a variety of dependency levels and diverse needs. The registered manager told us that she reviewed staffing levels on a regular basis, taking account of the occupancy and dependency levels of the people accommodated, which demonstrated good practice. Assessment of staffing rotas and information from the AQAA and staff personnel records demonstrated that the home was maintaining satisfactory staffing levels. Rotas had been improved to include codes for each shift to demonstrate numbers of staff and hours worked by each person. Care Homes for Older People Page 27 of 37 Evidence: The home had a stable staff team including 7 qualified nurses, 19 care staff, 9 ancillary staff and the Registered Manager. Three members of staff had left the homes employ since in the past 12 months, and four new staff had been recruited. We were told that there were no staff vacancies at the time of this inspection. We looked at a sample of personnel files, which were generally well organised with a recruitment checklist. The registered manager followed the organisations recruitment process, which were generally robust and provided safeguards for people living at the home. However the organisations application form only requested a 10 year employment history. A full employment history should be obtained with fully documented explanations of any employment gaps. One person had not given dates of employment or reasons for leaving previous employment. There were risk assessments in place for people employed on a POVA first basis but this process is no longer acceptable with the implementation of the Independent Safeguarding Authority (ISA). Risk assessments used prior to receipt of a new CRB should be expanded in compliance with up to date guidance from the ISA, including the named supervision arrangements. The registered manager continued to demonstrate a strong commitment to staff training and development to provide all staff with appropriate training to raise awareness and skills to respond to peoples changing needs. All care staff had achieved an NVQ level 2 care award and nine care staff had achieved the NVQ level 3 award with two additional carers enrolled as candidates. People living at the home and visitors told us staff were caring and helpful. We spoke with a visiting physiotherapist who told us it was a pleasure to visit this home and the staff were welcoming, knowledgeable and resourceful. The staff told us they felt supported and enjoyed working at this home. Care Homes for Older People Page 28 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an effective management team providing good leadership and direction, which ensures continuity. There are systems for consultation with people living at the home. The systems for safeguarding people in their environment are not sufficiently robust. Evidence: Sue Scott had been the registered manager at Hollycroft Nursing Home for nineteen years. She was a Registered General Nurse (RGN) and had many years of varied nursing experience prior to her employment at this home. She had achieved the RMA (Registered Managers Award) and continued to demonstrate a commitment to her own professional development. For example she had a good awareness of the recently implemented Deprivation of Liberty Safeguarding Regulations and its implications for people living at the home. She planned to arrange for staff to receive appropriate training to raise their awareness and knowledge to benefit people using services provided at the home. She had undertaken training relating to nutrition, use of PEG feeding, MUST (Malnutrition Universal Screening Tool), End of Life Pathways, wound Care Homes for Older People Page 29 of 37 Evidence: care, and accredited level 2 training for infection control and dementia care. She told us she had three supernumerary days and two clinical shifts each week, which she considered to be sufficient for her managerial duties. She was ably supported by the deputy manager who had worked at the home for eleven years. During discussions there was evidence of an open, approachable ethos, which encouraged good communication with people living at the home, their relatives and staff. There were clear lines of accountability within the home, and through the management structure. We saw evidence that a representative of the organisation visited the home regularly. We looked at the Regulation 26 Reports undertaken by the area manager, held at the home, and noted that they were comprehensive and constructive. We were told that an external Quality Assurance company was providing audit tools to assist the organisation to develop a self auditing quality assurance system. We saw evidence that the registered manager had used some self auditing systems, which included monthly audits of areas such as food, the environment, staffing levels and accidents, incidents and falls, with remedial actions to minimise risks identified. This meant positive outcomes for people receiving the service. The registered manager had made good progress to improve care plans and care provided. However, as highlighted at the Health and Personal Care Section of this report, a number of improvements relating to medication administration were needed to give assurances that people would receive their medication safely and as prescribed by their doctor. We noted that staff meetings were taking place and there was a structured formal supervision system. The development of staff knowledge and skills had evident benefits for people living at the home. We noted that people were offered the opportunity to manage their own money if they wished, and the home provided facilities to help keep it safe. We looked at a random sample of balances and records of monies held in temporary safekeeping on behalf of people living at the home, which were accurate, with well documented records of all transactions. We looked at a sample of heath and safety and maintenance documentation, which was satisfactory and well organised. Staff received mandatory training appropriate to Care Homes for Older People Page 30 of 37 Evidence: their roles, such as fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training. As reported at the environment section, we saw people with bedrails in place, used with pressure relieving mattresses, where the height of bedrails was less than the permitted height dimension of 220mm from uncompressed mattress to the top of the bedrails. There were also sets of third party bed rails, which were loose, with excessive gaps. Although there were risk assessments in place, they did not include all of the high risk areas and there were no regular documented checks. This meant that the equipment could pose risks of harm to people whilst they were in bed. Care Homes for Older People Page 31 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 To seek advice and devise a protocol in accordance with NMC and RPSGB guidance for the administration of crushed medication via PEGs or naso-gastric tubes to include the dilution and flushes required. This is to make sure people are receiving their medication safely 01/04/2010 2 9 13 To ensure carried forward balances of medication stocks are recorded on MAR charts so that accurate audits can be carried out. This is to make sure people are receiving their medication as prescribed. 01/04/2010 3 9 13 To ensure variable dosages 01/04/2010 of medication are recorded, such as one or two tablets, 5 mls or 10 mls. Care Homes for Older People Page 33 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to make sure people are receiving their medication as prescribed. 4 38 13 Risk assessments for bed 19/03/2010 rails must be expanded to incorporate all areas of risk to the person, including risks of entrapment and incompatibility with the bed and or mattress; and staff must be provided with training, so that a competent person undertakes visual checks of bedrails in the home on a regular basis to ensure that they are safe. A record must be made of these checks. This is to ensure people living at the home are safeguarded at all times. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 1 2 The service user guide should be revised to include information about fees. The contract / terms and conditions of residence should be revised, updated and reissued to each person living at the home to and should reflect good practice guidance issued by The Office of Fair Trading. Assessment information should be fully completed and signed by the person and / or their representative to 3 3 Care Homes for Older People Page 34 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations demonstrate their agreement and involvement. 4 7 Care plans should include all of each persons assessed needs and should be appropriately evaluated and updated to accurately reflect all changes to health and care needs. There should be regular documented checks to ensure pressure relieving mattresses are maintained at the correct setting for each person. A risk assessment should be undertaken for the overall security of medication stored in the dedicated medicine room. This is to ensure that peoples medication is stored safely and securely. New signage should be obtained where oxygen is stored in compliance with up to date guidance to show the inflammable gas storage. A fridge thermometer, which records daily minimum and maximum temperatures over each 24 hours, should be obtained, with records to show that the medication fridge temperatures are maintained between 2 degrees C and 8 degrees C at all times. A system should be devised for recording the application of creams and topical applications. Clarification should be sought from the prescriber or pharmacist for as directed instructions, which do not provided staff with sufficient guidance for administration of medications and topical applications. An up to date medicines reference guide such as the BNF (British National Formulary) should be obtained for staff guidance. Inventories of personal possessions should be fully completed, updated, signed and dated by the person or their representative and witnessed by the member of staff. Menus should be produced in alternative formats for people who cannot read or understand the written menus to help them make realistic choices. The complaints procedure should be revised and updated and should be available in appropriate formats so that people can understand their rights. The home policies and procedures relating to safeguarding Page 35 of 37 5 8 6 9 7 9 8 9 9 10 9 9 11 9 12 14 13 15 14 16 15 18 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations vulnerable people should be revised, simplified and updated to reflect current good practice guidance. 16 18 All staff should be given time to read and familiarise themselves with the homes safeguarding procedures and the Safeguard and Protect procedure for vulnerable adults with signatures and dates to evidence their awareness. The maintenance and refurbishment programme should be completed in a speedy timescale for the comfort of people using the service. The defects in the heating system should be thoroughly investigated and resolved so that all parts of the home are maintained at an ambient temperature for the comfort and welfare of people living at the home. The laundry procedure and infection control guidelines should be displayed in the laundry area for staff guidance. Application forms should be expanded to include a full employment history and an explanation of all employment gaps or queries should be fully documented. 17 19 18 25 19 20 26 29 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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