Inspection on 11/01/06 for Hollies, The

This inspection was carried out on 11th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hollies, The 23/11/09

Hollies, The 26/09/07

Hollies, The 22/09/06

Hollies, The 08/06/05

Hollies, The 01/11/04

Hollies, The 12/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Hollies, The 9-11 Fox Lane London N13 4AB Lead Inspector Mr David Hastings Unannounced Inspection 10:00 11 January 2006 th 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 Hollies, The DS0000010571.V261333.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. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hollies, The Address 9-11 Fox Lane London N13 4AB 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) 020 8886 3068 tracysimcock@btbroadband.com Mr John Phillips Mrs Patricia Phillips Tracy Simcox Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Four specified service users who have dementia may remain accommodated in the home. The home must advise the registering authority at such times as any of the four specified service users vacates the home. 8th June 2005 Date of last inspection Brief Description of the Service: The Hollies is a private care home registered to provide care and support for a maximum of nineteen people over the age of sixty-five years. The aim of the home is to ensure that service users feel safe and relaxed as they would in their own home, but with the added security of knowing that help is always on hand if they need it. The home is a large detached Victorian, two-storey building with 15 single and 2 double bedrooms located on the ground and first floors. There are two bathrooms and two toilets on the first floor and an assisted bathroom and two toilets on the ground floor. The home has kept many of the original Victorian features. The manager’s office, lounge, dining area, kitchen and laundry room are on the ground floor. There is a small parking area at the front of the home and a well-maintained accessible garden at the back of the home. The home is situated on a residential street, close to a variety of shops, restaurants and public transport located along the high street at Palmers Green. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 11th January 2006 and lasted four hours. Prior to the inspection the CSCI received 15 comment cards from service users, 11 comment cards from relatives and 7 comment cards from health care professionals. Without exception all comments received by the CSCI were very positive regarding the care provided at The Hollies. Service users indicated that they felt well looked after. Relatives were impressed with the openness of the staff and the manager. Health care professionals indicated that staff were always helpful and the home was clean. On the day of the inspection the inspector spoke with six service users and two relatives. A partial tour of the premises took place and care records were inspected. The inspectors were assisted throughout the inspection by the registered manager. All staff, the registered provider and registered manager were open and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Four new requirements have been issued as a result of this inspection. Ketchup bottles must be stored in a fridge once they are opened. Individual parts of each meal must be pureed separately for those service users with swallowing Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 6 problems. The manager must ensure that staff undertake a competence test with regard to the administration of medication and the fire emergency plan needs to be reviewed regularly. The inspector is confident that these requirements will be complied with by the registered manager within the timescales given. 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. Hollies, The DS0000010571.V261333.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 Hollies, The DS0000010571.V261333.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): 3 and 4 Detailed assessments are provided by trained professionals for all service users before they are admitted to the home. The staff and management know the service users very well and are able to meet their individual needs. EVIDENCE: Two new service users have been admitted to the home in the last few months. There was evidence that comprehensive assessments had been carried out prior to the service users moving in. The registered provider has applied and received a minor variation for four specified service users with dementia to continue to be accommodated at the home. The registered provider and registered manager have decided not to pursue a major variation to their conditions in order that service users with a diagnosis of dementia can be admitted to the home. These were both requirements of the last inspection that have now been complied with. Relatives, visitors and service users that the inspectors spoke with were very positive about the care provided by the home. It was clear from discussion with the registered manager and registered provider that they knew the service users very well and were aware of how to meet each service user’s individual needs. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Service users’ health, personal and social needs are clearly identified in their individual care plans. Service users have good access to health care professionals. Although medication records were generally satisfactory, the manager must review the competences of all staff who administer medication at the home. EVIDENCE: Four care plans were examined. There was evidence of consultation and of the service user plans being reviewed on a monthly basis. The assessed needs were reflected in the care plans. Risk assessments in respect of falls and manual handling were in place. It was clear from discussion with service users that they felt their needs were being met. One service user told the inspector “If you have to go somewhere you should come here”. The inspector found up-to-date records of health care appointments attended such as dentist, hygienist, GP, audiologist, chiropodist, optician and district nurse records also contained detailed outcomes. Emotional and social health needs had also been detailed in service user plans. Risk assessments were in place for service users who were considered to be at risk of developing Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 10 pressure sores. The home has provided a pressure sore mattress for several service users as a preventative measure. It was reported that no service users have pressure sores. Two requirements were issued at the last inspection that no medication is left in service users’ rooms and that medication can only be crushed with written permission from the GP. Both these requirements have now been complied with. Records in relation to the receipt, administration and disposal of medication were examined. These records were generally satisfactory however the inspector found a number of inaccuracies with the recording of medication given to service users. This was discussed with the registered manager and registered provider. It appears that most of the staff team give out medication in the home. Although all staff concerned have attended medication training, the inspector was concerned about staff continued competence to record the administration of medication. As a result a requirement has been issued that the registered manager carry out an individual competence test for all staff who administer medication. Only those staff who have demonstrated satisfactorily competence can administer medication at the home. The registered manager must record a list of these staff within the medication records. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 The home has a lively atmosphere and there is a good range of activities available. Service users receive a wholesome, appealing diet in pleasing surroundings. EVIDENCE: The home arranges quizzes, scrabble competitions, entertainers, poetry reading, concerts, clothes show and singing sessions. Service users were observed talking to each other, laughing and generally enjoying the company of each other. Staff also spent lots of time interacting with the service users and joining in with conversations. Service users social, emotional and leisure preferences are documented in their service user plans. One visitor commented that, “the staff are very good”. Service users and relatives commented that the recent Christmas celebrations were very successful and the party had been a lot of fun. The registered manager informed the inspector that more days out of the home have been organised and a number of service users had been out on a trip to Southend. The kitchen was clean and tidy and the cook was making a homemade quiche on the day of the unannounced inspection. Service users commented that the food was very good. The menus were varied and there was a large amount of fresh ingredients used. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 12 Two requirements have been issued at this inspection that ketchup bottles are stored in the fridge after opening and that meals given to service users with swallowing problems are pureed separately. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home takes complaints seriously and deals with them in a professional manner. Service users are protected from abuse by clear policies and procedures and appropriately trained staff. EVIDENCE: There have been two complaints made since the last inspection. The homes complaints record documented clearly the nature of the complaint, the investigation and the outcome of the investigation and if the complainant was satisfied with the outcome. The home had a complaints procedure that meets the requirements of this standard. Service users and relatives spoken to said that they were happy with the support provided and that they did not have any cause to complain. They were familiar with the homes complaints procedure and felt confident that any complaint made would be dealt with appropriately by the registered person. The home has a copy of the local authorities adult protection policy and procedure in place. The registered manager has undertaken abuse awareness training and records showed that she has presented adult abuse training with the staff at the home. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home is clean, safe and well maintained. Suitable systems are in place to ensure that a good standard of hygiene is maintained. EVIDENCE: The home is well maintained and provides a homely environment for the service users. The home is decorated to a good standard. The registered provider has fitted radiator covers to all radiators in the home and thermostatic valves to all wash hand basins. Lighting is domestic in character and service users are able to regulate the temperature in their own rooms. The home was very clean and free from offensive odours. The home employs a cleaner to clean all communal areas. There were appropriate infection control policies and procedures in place. The laundry was clean and there are suitable washing machines in place. The inspector was informed that staff are currently undertaking a distance learning course in infection control. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 15 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): 27 The staff working at the home are able to meet the needs of the service users living there. EVIDENCE: At the time of the unannounced inspection there were sufficient staff on duty to meet the needs of service users. At the time of the unannounced inspection there were three care staff on duty as well as the manager, cook and domestic assistant. There is one waking night staff and one sleeping in staff for nineteen service users. Staffing levels had been agreed with the CSCI. Service users commented that the staff were very good and that they felt supported by them. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 16 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, 32, 35, 36 and 38 Service users live in a home that is well run by a dedicated and professional manager who understands her responsibilities and has good communication skills. Service users’ financial interests are safeguarded by clear accounting procedures. Staff are appropriately supervised. There are good systems in place to monitor health and safety compliance. EVIDENCE: The registered manager is a qualified nurse and will be completing her RMA in June 2006. Both service users and relatives that the inspector spoke with were very positive regarding the manager of the home. One relative commented that the manager was very proactive in her approach to managing the home. A requirement, issued at the last inspection, that regular staff meetings take place at the home has now been complied with. The registered provider informed the inspector that the home does not hold any money on behalf of Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 17 service users. Service users or their representatives are invoiced every quarter for items such as hairdressing and toiletries. The inspector examined the invoice system and there were clear audit trails in place including copies of all receipts. Records in connection with staff supervision were examined. These indicated that staff were being supervised on a regular basis. This was a requirement from the last inspection that has now been complied with. A requirement restated at the last inspection that risk assessments must be produced for all safe working practices has now been complied with. Records indicated that emergency lighting is checked on a regular basis as well as all fire call points. A satisfactory electrical installation certificate was seen. These were three requirements from the last inspection that have now been complied with. The inspector saw evidence that temperature checks on wash hand basins are carried out every month. This was a requirement from the last inspection that has also been complied with. The inspector noted that the fire evacuation procedure had not been reviewed for some time. A requirement relating to this has been issued in the relevant section of this report. All other records in relation to health and safety that were examined were satisfactory. Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 X 2 Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered manager must carry out an individual competence test for all staff who administer medication. Only those staff who have demonstrated satisfactorily competence can administer medication at the home. The registered manager must record a list of these staff within the medication records. The registered manager must ensure that all ketchup bottles are stored in the fridge once they are opened. The registered manager must ensure that individual parts of each meal are pureed separately for those service users with swallowing problems. The registered manager must ensure that the emergency fire plan is reviewed in consultation with the fire authority. Timescale for action 01/03/06 2. OP15 13(4) 01/03/06 3. OP15 16(1)(i) 01/03/06 4 OP38 23(4)(e) 01/04/06 Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 20 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 Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Hollies, The DS0000010571.V261333.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!