Care Home: Holyport Lodge Nursing Home

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Annual service review Name of Service: Holyport Lodge Nursing Home The quality rating for this care home is: The rating was made on: three star excellent service 0 3 0 3 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme 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 review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Helen Dickens Date of this annual service review: 1 2 0 3 2 0 1 0 Annual Service Review Page 1 of 7 Information about the service Address of service: Holyport Maidenhead Berkshire SL6 2JA 01628781138 01628781707 bupacarehomes.co.uk www.bupa.com BUPA Care Homes (BNH) Ltd Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Name of registered manager (if applicable) Mrs Lisa Mitchell Conditions of registration: Category(ies) : old age, not falling within any other category physical disability Conditions of registration: Number of places (if applicable): Under 65 Over 65 0 4 41 0 The maximum number of service users who can be accommodated is: 45 The registered person may provide the following category/ies of service only: Care home with nursing - 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 - OP Physical disability - PD Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: The previous manager left soon after the last inspection and a new manager has been appointed and has since registered with the Commission. 0 3 0 3 2 0 0 9 Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Annual Service Review Page 2 of 7 Holyport Lodge is a large 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, some of whom may have a physical disability. The home has been converted but retains many of its original features and character, including an oak staircase and hand carved oak panelling. There is a drawing room with a grand piano, a TV room overlooking the terrace and gardens, an activities room, and a large well furnished dining room. 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. Current fees range from £900 for residential care, to £1500 for full nursing care. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection on 03/03/2009. This included: The annual quality assurance assessment (AQAA) that was returned to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Responses to any surveys we sent out. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations including those who commission this service on behalf of social services clients. What other people have told us about the service. A telephone interview with the Registered Manager on 12/03/2010 What has this told us about the service? The AQAA was returned on time and stated the following improvements had been made since the last inspection: - Menus have been changed and different activities introduced, as a result of preferences expressed by residents. - There are now 12 themed activities, one for each month. - A regular morning event will be starting on 22nd March in the lounge, offering a variety of activities for example current affairs, a guest speaker, or a sherry morning. - All staff are now trained in showing prospective residents and families around the home. - More residents reviews have included families and the multi-disciplinary team. - The internal assessment document, QUEST, has been up-dated and improved following feedback during its use in the last year. Annual Service Review Page 4 of 7 - The BUPA nite bite menu is now up and running. - Housekeeping improvements ensure the dining room is cleaned more thoroughly, and there is now a member of the housekeeping team on the late shift. - Better planning and record keeping in relation to training by the training co-ordinator who was appointed a year ago. - A new gardener has been appointed and has plans to make the gardens more user friendly for residents. A selection of surveys were sent out for the home to distribute and seven were returned to the Commission. Three returned from staff indicated they had had proper recruitment checks prior to starting work, and had had suitable training. In response to the question about whether they thought there were enough staff to meet peoples needs, two ticked Usually and one ticked Sometimes. There were some positive comments from staff including: Provide high standard of care; maintain privacy and dignity; and provide high standard of food and catering. Another wrote: Meals on time; occupational therapy 5 days per week. However, there were also some mixed comments relating to pay, and one noted more staff time was needed for residents who need company. There was also a comment that some staff do not speak good English. These and other comments were passed to the manager for her attention. Four surveys were returned from residents and positive comments included: The overall care is not bad, and the staff doing the OT programme are excellent. Food is good and activities always enjoyable. Staff take time to listen. In response to the question What does the home do well?, one person wrote Everything. However there were also some concerns including one relative who noted that staff did not always take requests on board although at the time requests are made it appears what has been requested will be done. This person noted there is a great staff turnover and staff training could be better. A resident noted that whilst meals were enjoyable, the service at lunch could be better ..it always seems rushed. In discussion with the manager by telephone, she said some issues raised on surveys had already been dealt with as they had been raised at recent residents and relatives meetings and already attended to. The AQAA stated that only 11 of the 26 care staff have the equivalent of an NVQ qualification. However, the manager said that since the AQAA had been completed, two new care staff had been taken on who had overseas nursing qualifications, and there were always 2-3 staff members studying for NVQs. She said the home was now nearly full and the majority of new staff taken on to care for the higher number of residents, had not had qualifications in care. She said that once their 3 month probationary period was completed, the new staff would be offered the opportunity to do NVQ qualifications. The AQAA asks whether the home has a list of specific policies and procedures in place and when these were last reviewed. It appeared that all the policies and procedures were last reviewed in 2006 which means they are overdue for review. The manager said she would look into this with the responsible individual for the service. Annual Service Review Page 5 of 7 According to their AQAA the service has received one complaint in the last twelve months and this was dealt with within the time frame of their complaints procedure. It stated there had been no safeguarding adults investigations at the home. No complaints have been made to the Commission about this home, and one issue alerted to CQC by the home concerning a medication error, was forwarded to the local safeguarding adults team and it was decided that no further investigation was needed. The last report noted that: Care planning arrangements are very well managed and residents involvement in their own care is evident from the very detailed instructions to staff found on those care plans sampled. What are we going to do as a result of this annual service review? We are not going to change our inspection plan and will carry out the next Annual Service Review by 03/03/2011. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. 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