Inspection on 22/09/06 for Hollies, The

This inspection was carried out on 22nd September 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 11/01/06

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 Steve Boyd Key Unannounced Inspection 22nd September 2006 11:25 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.V308920.R01.S.doc Version 5.2 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.V308920.R01.S.doc Version 5.2 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 johnoak@blueyonder.co.uk 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.V308920.R01.S.doc Version 5.2 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 five specified service users vacates the home. 11th January 2006 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. Fees charged at the home range between £399 and £450. A copy of this report can be requested directly from the home or accessed via the CSCI website (web address on page 2 of this report) Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place in one day in September 2006. Three service users were spoken with in private and others in general. Three staff were spoken with during the inspection. A tour of the premises was undertaken and various records and policies were considered. Prior to and during the inspection, a total of twenty comment cards were received. Fourteen from relatives and visitors, four from health professionals and two from service users. The inspector was assisted throughout the visit by the manager, Tracy Simcox, and the proprietors Mr and Mrs Phillips. What the service does well: What has improved since the last inspection? What they could do better: As a result of this inspection, two requirements and one recommendation have been made to further improve the care service at the home. A few omissions were seen on the medication administration record sheets, therefore, staff need to be aware of the importance of accurate recording. A couple of carpets in service users bedrooms need to be replaced to enhance the environment and staff files would benefit from indexing to allow for easier retrieval of information. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 6 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.V308920.R01.S.doc Version 5.2 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.V308920.R01.S.doc Version 5.2 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 6 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users do not move into the home without having their needs assessed and the knowledge that these will be met. EVIDENCE: The file of a service user admitted to the home since the previous inspection was seen. This indicated the person had a full assessment prior to moving into the home. A comment from a service user in a card received prior to the inspection stated “ I came and had lunch and met everyone before I moved in” which is in line with the homes policy on admitting new service users. Other files seen during the inspection also indicated assessments of service users needs are carried out prior to them being admitted to the home. The home does not offer an intermediate care service. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and10 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users have individual care plans based on a holistic assessment. Their health care needs are given a good level of priority. They are treated with respect and privacy is a core value of the home. The homes procedures in respect of medication administration need some tightening. EVIDENCE: Service users sampled were found to have individual care plans including daily care plans. The plans had goals based on holistic assessments and there were actions identified as to how these goals could be met. Reviews of care plans on a monthly basis were seen to have taken place. A good daily recording system was in place linking into the care plans. Risk assessments were seen to be available for service users. These included risks associated with moving and handling. Risk assessments had actions identified as to how to minimise risk to the service user and had been regularly reviewed. Pressure sore risk assessment had also been undertaken. Service users health care needs were given a high priority by the home. Records seen showed evidence of regular appointments with different health Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 10 professionals such as G.Ps. opticians, dentists and chiropodists. Assessments and care plans were seen to give a good level of emphasis to health care needs of individual service users. The home operates a monitored dosage system of medicine administration. This was seen to be generally working well at the time of inspection. A requirement to keep a list of staff deemed competent to administer medication had been met. Service users indicated that they were given medication at the correct times. Some omissions in recording medication administered were found on the administration record sheets. The manager was advised to discuss with the staff involved and to carry out periodic audits to lessen the chance of this recurring. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 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): 12,13,14 and 15 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users benefit from various activities and entertainment. They have contact with family and friends as they wish. Service users have choice and control in their lives at the home. Service users benefit from good meals in pleasant surroundings. EVIDENCE: The Hollies offers its service users various activities in which they can take part or not. These include: keep fit, scrabble, card games, bingo, discussion on current affairs and movie afternoons. Service users also follow their own interests such as watching television or reading. A local vicar comes to the home periodically to see service users and give communion. In the past summer months; a couple of outings have taken place, which were enjoyed by service users. The majority of service users have contact with family or friends. Service users stated their visitors were made to feel welcome and could visit at any time. Comment cards received form relatives and friends were all positive about the home and confirmed they are made to feel welcome at the home. Service users spoken with during the inspection said they were able to move freely around the home and were not subject to rigid routines such as when to Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 12 get up and go to bed. Service users have meetings they can attend where family are invited to discuss the home and improvements they may like to see. One service user stated, “ You can’t fault this home” Comments from service users regarding the quality and quantity of food at the home were all positive. Plenty of stocks were seen on the day of inspection and the lunchtime meal looked appetizing. Service users likes and dislikes in respect of food are known by staff and alternatives to the main meal are always available. The dining room is a pleasant eating area. Requirements made at the previous inspection regarding ensuring ketchup is kept in the fridge after opening and food stuffs are liquidized individually had been met. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users, their relatives and friends are confident that their complaints would be taken seriously and dealt with professionally. Service users are protected from abuse by the homes policies and procedures. EVIDENCE: There have been no complaints recorded by the home since the previous inspection and none made to the CSCI. The home has a suitable complaints policy and procedure which aim to resolve any complaints both speedily and effectively. Service users spoken with during the inspection did not have any concerns or complaints. One commented that should they have any, they were confident the manager “ would take action right away.” Staff have received training in the protection of vulnerable adults from abuse. A policy and procedure is available. The home also has a copy of the local authorities adult protection policy. No referrals regarding protection of vulnerable adults have been made since the previous inspection. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users live in a safe and generally well - maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The Hollies was found to be well decorated and generally well maintained at the time of the inspection. Since the previous inspection, the lounge and dining areas have been redecorated as well as one bedroom. Service users bedrooms were personalised with plenty of evidence of pictures and photographs. The home was found to be clean and tidy and service users confirmed this was always the case. On the day of inspection, no obvious safety hazards were seen. Potentially dangerous chemicals were all locked away. There were no offensive odours in the home and the home was warm and comfortable. There is a pleasant rear garden area for service users to utilise in better weather. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 15 The home had appropriate infection control policies and procedures in place, staff have had distance learning training in this area. There were a couple of bedrooms, which had carpets, which were quite stained, in places. A requirement is made that these are changed over the next six months. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and30 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. The mix of staff skills and numbers on duty meets Service users needs. Service users benefit form a trained and competent workforce recruited in an appropriate manner. EVIDENCE: The home had three care staff and the manager on duty at the time of inspection. There was also a cook and domestic member of staff. The numbers of staff were sufficient to meet the needs of service users and remain as agreed previously with the CSCI. Service users spoken with were very complimentary about the staff who work at the home. One comment received from a resident was “Staff are very good here” Staff spoken with felt there was an adequate number of them to meet the needs of the current service user group. Fifty percent of the care staff working at the home have achieved National Vocational Qualification at level two or above. Five staff are currently undertaking or about to commence nvq’s. Thus the home has a demonstrable commitment to ongoing and relevant training. Each staff member has an individual training record. Training carried out has included: food hygiene and abuse training over the past months. In the coming months as well as nvq training, a number of staff are to undergo training on Dementia and Medication issues. Refresher courses in first aid and moving and handling are also planned. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 17 The home as well as a training policy has a recruitment policy. An examination of staff files showed that staff are subject to filling in application forms, undergoing interviews, having references taken up if successful and being checked by the Criminal Records Bureau before commencing employment. Photo – identity is also checked by the home. Staff confirmed that these processes take place and that they also undergo an induction programme. Staff presented as pleasant and committed to service users receiving good care. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 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 and 38 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. The home is run by a professional person with a caring personality. Service users best interests fully inform the operation of the home. The health, safety and welfare of service users and staff is promoted and protected. EVIDENCE: The manager, Tracy Simcox has been the manager for several years. She is awaiting the certificate for the Registered Managers Award training she had recently completed. She is also a qualified nurse. Service users, staff and relatives via comment cards all expressed confidence in her management of the home and the inspector certainly found her open and approachable during the inspection visit. Service users best interests are promoted by the operation of the home, which is run in a way that treats people as individuals. Staff were seen being respectful and helpful during the inspection. Meetings are held periodically Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 19 which enable service users to voice any issues they feel would aid the running of the home. The home does not hold any monies on behalf of service users. Liability insurance is held and was up to date. A requirement of the previous inspection was to ensure the home’s fire evacuation procedure had been reviewed with fire officers. This had been achieved. Safety certificates were seen for gas and electrical installation. A health and safety policy was available as well as COSSH assessments. There were no safety hazards seen at the time of inspection. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 21 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 ensure that all medication is signed for at the time of administration. The registered providers must renew the bedroom carpets indicated in standard 19 of this report. Timescale for action 31/10/06 2. OP19 23(2) 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations It is recommended that staff files are indexed for ease of information retrieval. Hollies, The DS0000010571.V308920.R01.S.doc Version 5.2 Page 22 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.V308920.R01.S.doc Version 5.2 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. 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. 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