Inspection on 27/10/05 for Hollies Care Home

This inspection was carried out on 27th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hollies Care Home 30/10/07

Hollies Care Home 14/11/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hollies Care Home Reading Road Burghfield Common Reading Berks RG7 3BH Lead Inspector Susan Burton Unannounced Inspection 27th October 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 DS0000065501.V249916.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. DS0000065501.V249916.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hollies Care Home Address Reading Road Burghfield Common Reading Berks RG7 3BH 020 79293444 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) Ashbourne Holdings Ltd Post Vacant Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places DS0000065501.V249916.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Hollies Nursing Home is now under the ownership of Ashbourne Healthcare having changed hands in October 2004. The home is registered for fifty-eight male or female individuals over retirement age in mainly single furnished rooms and three double rooms. The Hollies has a new two-storey wing that has been added to the older part of the house providing 27 en-suite bedrooms. The new wing has added extra assisted bathrooms, walk in showers and lounge and dining rooms to both floors. The home is situated in a quiet semi-rural area with views at the rear over farmland and has an enclosed central courtyard with seating provided. DS0000065501.V249916.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 Thursday 27th of October 2005, the inspection commenced at 09.15 and finished at 14 .50. The home was visited by a Fire Officer from the Berkshire Fire and Rescue Service during the inspection to assess whether the home had met a previous fire deficiency notice that had been issued. The inspector worked with the Fire Officer for a proportion of this inspection to ensure a better understanding of the issues. The remainder of the inspection looked at how the home had met the requirements from the last inspection and feedback from residents and the homes quality assurance survey. This was a mostly positive inspection with a number of improvements seen. What the service does well: What has improved since the last inspection? Since the last inspection care plan documentation has improved, the monitoring of residents fluid intake has also improved. Confirmation has been provided to new residents that the home will meet their needs. The manager has organised a quality assurance survey to get feedback from residents and relatives on the quality of the service and the catering. DS0000065501.V249916.R01.S.doc Version 5.0 Page 6 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. DS0000065501.V249916.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 DS0000065501.V249916.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): 1,3,5 The homes Statement of Purpose has been updated a copy is to be sent to CSCI. The Service User Guide had not been separated from the Statement of Purpose and had not been made available as required to each resident. Pre-assessment information recorded evidenced that individuals recently admitted had their needs appropriately assessed, and written confirmation was provided that the home would meet those needs. Evidence was seen of trial stays and review meetings. EVIDENCE: A requirement from the previous inspection that a copy of the new updated Statement of Purpose and Service User Guide be sent to CSCI had been partly met. A requirement that all residents in the home will have a copy of the updated Service User Guide had not been fully met. Copies had been placed in communal areas but had not been made available to each individual as required. The Service User Guide is combined with the Statement of Purpose DS0000065501.V249916.R01.S.doc Version 5.0 Page 9 and as stated at the last inspection should ideally be separated for ease of use by the residents and their families. The home has a well-organised format for recording information following a pre-assessment visit. Details included family history, medical diagnosis and medication needs plus any communication issues and the family involvement. From examination of care plans the inspector was able to see that trial stays are offered, take place and have review meetings at the end to ensure that residents are satisfied the home is right for them and that the home can meet their needs. DS0000065501.V249916.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,11 The home has detailed plans of care, which set out each individuals needs. Residents and relatives had been consulted or involved with the care plans. The monitoring of fluid provision had been improved. Nutritional assessments were organised and detailed and evidenced regular review. The records evidenced that assessment of an individuals psychological and emotional needs had taken place. A partial inspection of the homes medication administration procedures took place; this was seen to be satisfactory. A recommendation from the previous inspection that information be placed in the home in regard to differing cultural beliefs had been acted on. Care plans evidenced individuals requests and wishes in regard to their cultural/funeral arrangements. EVIDENCE: The organisation has a detailed template, which the home uses to formulated care plans. These were seen to be fully utilised and well detailed. A wide DS0000065501.V249916.R01.S.doc Version 5.0 Page 11 range of information had been recorded; this included falls risk assessments, manual handling risk assessments, communication needs and assessments of skin integrity. Assessment of the individuals management of pain was included along with coping skills. The manager advised the inspector that following the last inspection the home had improved its practice in the monitoring of fluid and dietary intake, wound management and pressure relieving care. Care plan documentation evidenced more detailed assessment and review. From a tour and visits to residents bedrooms the inspector was able to see the improvements. Changes had been made in the management overview of the care practices. The inspector discussed medication administration with the care manager and followed her for part of the round to observe practice. The medication administration sheets had photographs of the individual residents and charts were seen to be correctly filled in. Two bottles of eye drops were seen to be out of date, otherwise the storage and administration were seen to be satisfactory. The homes controlled and scheduled drugs were not examined at this inspection. A recommendation made to provide information on individuals spiritual needs had been acted on. The manager had obtained a copy of the book, which provided staff with details of differing cultural rights, rituals and beliefs in regard to death and dying. Care plans were seen to detailed consultation with the residents or their family in regard to spiritual and funeral wishes. DS0000065501.V249916.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 Residents in the home are provided with a range of activities and events. The activity organisers post is currently vacant. Visitors were seen coming and going during the inspection and been made welcome. The staff arrange outings and events for residents and will organise events in the home for those that are not able to get out. Residents confirmed that they are able to exercise choice and control wherever possible within their daily lives. EVIDENCE: The manager advised the inspector that the activity officers and post was still vacant. The existing care staff were covering the post. The home as administrator also spends time with the residents organising and arranging events such as arts and crafts and bingo parties, she will also provide hand massages for those not able to leave their room. Visitors were seen being welcomed into the home. Residents are taken out for pub lunches by staff if wished, shopping trips are organised. Theatre shows are arranged in the home and posters around the home were seen advertising the Christmas pantomime. Holy Communion takes place every month. One resident commented how much she enjoys the visits from the mobile library DS0000065501.V249916.R01.S.doc Version 5.0 Page 13 and how useful the homes shopping trolley was. All residents spoken to were complimentary in regard to the care and kindness of the staff in the home. The member of staff who organises the shopping trolley had come in during her annual leave to make sure that residents did not go without this service. Items are purchased at cost price and sold to the residents without profits being made. The care plans provided details of the consultation with the individual resident in regard to their routines. Residents are asked their preferences for the time they get up in the morning and the time they go to bed, how many pillows they would like and how they would like to be addressed by staff. DS0000065501.V249916.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected at the last inspection. EVIDENCE: DS0000065501.V249916.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home is required by CSCI to consult with the fire authority to ensure that adequate precautions are taken against the risk of fire and that the home complies with any advice and guidance issued by Berkshire Fire and Rescue Service. A requirement for the last inspection that confirmation was sent that all works were completed as required by the fire authority is still outstanding. EVIDENCE: Following a visit from the Berkshire Fire and Rescue Service in September 2004 the home had been issued with a fire deficiency notice. A Fire Officer had visited in March 2005 and was still not satisfied that the home had fully complied with their advice and guidance. The Fire Officer, Inspector and homes manager took a tour of the building and found a number of fire doors potentially defective. The homes fire risk assessment had been completed but still needed minor details to fully comply with the Fire Officers standards. The home is to demonstrate that the fire risk assessment is satisfactory in the opinion of the DS0000065501.V249916.R01.S.doc Version 5.0 Page 16 fire authority and that they have taken any necessary actions as required by the significant findings of the fire risk assessment. The home had risk assessed certain bedrooms and had provided a number of hold open devices for bedroom doors. DS0000065501.V249916.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 The home currently has only 2 staff that have completed NVQ 2 or above. EVIDENCE: The manager submits each month to the organisation and NVQ training status report. This evidenced that only 2 staff have currently achieved NVQ 2 or above and that 14 of the homes care staff are currently in progress towards achieving completion of their NVQs. The standard recommends that a minimum ratio of 50 of care staff achieve NVQ 2 or above by (December) 2005. This standard will be followed up at the next inspection DS0000065501.V249916.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): 31, 33, 35, 37, 38 The manager has now been in post for 4 months and is required to be registered by CSCI. The manager has organised a quality assurance survey for residents and relatives. Residents finances are safeguarded by the homes procedures. The homes record-keeping policies and procedures appear to safeguard residents rights and best interests. Accident reporting is confidential and patterns and trends are monitored. The home needs to review its lighting provision in certain areas of the home to ensure that it is safe for residents and suitable for staff purposes. EVIDENCE: DS0000065501.V249916.R01.S.doc Version 5.0 Page 19 The new manager has now been in post 4 months. No application has been received by CSCI for her registration; the managers CRB check has also not been completed. The manager is required to be registered with CSCI. The inspector was able to see approximately 15 of the quality assurance survey results from August. The forms were sent to relatives and also placed in residents rooms. The survey asked a number of questions in regard to catering and the quality of care provided in the home. An analysis of the survey has yet to be completed. From examination of a random sample the responses appeared to be generally very positive. One result had been very critical and the manager had followed this up by having a discussion with the relatives to resolve the issues. The inspector spent some time with the homes administrator. She has a system in place, which records residents financial balances and any transactions made by them or on their behalf, receipts are kept and balance sheets were available. The home has a weekly pocket money reconciliation sheet, which lists all balances and is counter checked by the manager and the organisation. The home has a safe for keeping small sums of residents money. Generally record keeping in regard to care planning and assessments had improved since the last inspection. Monitoring of records had also improved. The homes accident book evidenced that appropriate accident reporting takes place, accident records are confidentially filed. From a tour of the building the inspector found that the ground and upper floor corridors by the nurses stations were very poorly lit and seemed quite dark in comparison to other areas in the home, the carpet was also quite dark in colour and could have been potentially hazardous for those with poor sight. The staff use this area for administration and documentation, the current domestic style lighting does not appear to be sufficient for the purpose. These were the only aspects of the standard inspected at this time. DS0000065501.V249916.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 3 2 DS0000065501.V249916.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 (2) Requirement Timescale for action 27/01/06 2 OP19 23 (4) 3 4 OP31 OP38 8 13 (4) a, c A copy of the Service User Guide is to be supplied to each resident. Repeated requirement The Responsible Person confirms 27/01/06 in writing to CSCI that all work required by the Berkshire Fire Authority are completed. This is a further repeated requirement. The manager is to be registered 27/01/06 with CSCI The home is to review its lighting 27/01/06 provision in corridors and nurses stations to ensure that area is safe for the residents and is suitable for staff purposes. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000065501.V249916.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 DS0000065501.V249916.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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