Inspection on 26/09/07 for Hollies, The

This inspection was carried out on 26th September 2007.

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 22/09/06

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 Mr David Hastings Key Unannounced Inspection 09:30 26 September 2007 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.V344221.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.V344221.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.V344221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five 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. 22nd September 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 £460 and £485. 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.V344221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 26th September 2007 and lasted seven hours. I was assisted throughout the inspection by the registered manager and the two registered providers of the home who were very open and helpful. I spoke with four staff, four visitors and eight residents of the home. I inspected the building and examined various care records as well as a number of policies and procedures. All of the residents I spoke with said they were very happy with the care and support they received. One resident told me the staff, “Treat me very well”. What the service does well: What has improved since the last inspection? What they could do better: One requirement has been issued relating to formalising the home’s quality assurance systems so that residents and their representatives are able to see how well the home is meeting the aims and objectives of the service. Three good practice recommendations have been issued relating to residents having a say in how their care is delivered, staff recruitment practices and fire drills for night staff. The CSCI is confident that these will be complied with by the registered manager and registered providers within the timescales given. Hollies, The DS0000010571.V344221.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. The summary of this inspection report can be made available in other formats on request. Hollies, The DS0000010571.V344221.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.V344221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 not applicable) People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home carries out a comprehensive assessment of individual’s needs so that they know that the home is suitable for them before they decide to move in on a trial basis. EVIDENCE: I examined assessments of people who have recently moved into the home. These assessments were detailed and covered all the requirements of Standard 3.3 of the National Minimum Standards for Older People. People confirmed that either themselves or their relatives had visited the home prior to moving in on a trial basis. Residents I spoke to said that the staff knew them well and understood their needs. It was clear from discussion with the manager and owners of the home that they understood the importance of making sure the home could properly support the person before a decision to move in was made. Hollies, The DS0000010571.V344221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Six care plans were examined. These plans were holistic in approach and set out the plan of care for each individual for staff to follow. The plans set out the health, personal and social needs of residents. Staff I interviewed had a good understanding of the needs of the people in their care. Although plans were generally being reviewed and updated regularly residents did not appear to be involved in the review of their plans. A recommendation has been issued that residents views about the care provided to them are sought and recorded when care plans are reviewed. This will ensure that people have a say in how their care is provided. Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 10 From records and discussions with the manager it was evident that people have been supported to access health care. Residents told me that their health care needs were being met by the home. Records indicated that doctors, dentists, chiropodist, opticians and district nurses regularly saw residents. I was able to speak to a district nurse who was visiting the home on the day of the inspection and she confirmed that communication between staff and the district nurse team was very good. Satisfactory records were examined in relation to the receipt, administration and disposal of medication. Medication was being stored appropriately and the temperature of the medication storage area was being monitored and recorded. Only those staff who have completed the medication training are permitted to administer medication. The manager carried out regular medication audits to ensure that residents get the right medication at the right times and that staff are maintaining accurate records. Throughout the inspection I saw examples of staff treating people with respect and upholding residents’ privacy. For example staff were seen to be knocking on people’s doors before going in. People I spoke with confirmed that they were treated with dignity and staff upheld their need for privacy. Staff I interviewed were able to give practical examples of when they have upheld peoples’ privacy. Hollies, The DS0000010571.V344221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can choose from a range of activities at the home and are kept suitably occupied and engaged. Visitors to the home are made to feel welcome and can visit at any reasonable time. Residents are helped to exercise choice and control over their lives. The food provided is of good quality and mealtimes are relaxed and enjoyable. EVIDENCE: The Hollies provide various activities including: keep fit, scrabble, card games, bingo, discussion on current affairs and movie afternoons. Residents also follow their own interests such as watching television or reading. A local vicar comes to the home periodically to see residents and give communion. Residents that I spoke with said they were satisfied with the activities available to them. Both residents and visitors told me they enjoyed the trip out to Southend and other outings have taken place throughout the year. People commented that these trips out let them see staff in another light and brought them closer together. Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 12 I saw staff sitting and chatting with residents throughout the inspection and staff told me this was encouraged by the manager and was seen as an important part of the carer’s role. The record of visitors indicated that residents could have visitors at any reasonable time. The visitors I spoke with said they were always made welcome and offered tea or coffee when they visited. Visitors were very positive about the staff and management of the home. Residents I spoke with confirmed that visitors were welcomed. Residents confirmed that they were able to have choice and control over their lives at the home. Residents told me they could do what they liked and were not “bossed about” at all. Staff I interviewed were able to give examples of how they ensure people are able to exercise choice and control within their daily routines. The kitchen was inspected. The cook on the day of the inspection was aware of individual’s likes and dislikes as well as any special diets people may require. The kitchen was clean and there was a good selection of fresh food. Fridge and freezer temperatures were being monitored and recorded. People I spoke with were positive about the food provided by the home and confirmed that a choice of menu was always available. A resident commented, “You just have to ask”. One resident told me that the food was “Excellent”. Some residents joked that they have put on weight since being at the home! Lunchtime was a relaxed and staff were providing discreet assistance when required. Hollies, The DS0000010571.V344221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. Residents are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. One complaint had been received by the home since the last inspection. Records and discussion with the manager and owner indicated that this complaint had been dealt with fully and professionally. All the residents I spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. Staff were able to describe to me how vulnerable people could be at risk of abuse in a residential care setting. All staff were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that I spoke to said they felt safe and well supported at the home. Records indicated that staff have undertaken training in the protection of vulnerable people. Hollies, The DS0000010571.V344221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is safe and cleaned and maintained to a very good standard. EVIDENCE: I toured the building with the manager and visited a number of residents’ rooms. The building is well maintained and decorated to a good standard. As a result of the last inspection a number of carpets have been replaced in residents’ rooms. Everyone I spoke with commented on the homely atmosphere of The Hollies. The home had appropriate infection control policies and procedures in place, staff have had distance learning training in this area. Residents and visitors I spoke with said the home was always clean and there were no offensive odours detected throughout the home. A resident told me, “They keep my room nice and clean”. Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. All the staff at the home work very hard to meet the needs of residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. 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 current residents and remain as agreed previously with the CSCI. Residents spoken with were very complimentary about the staff who work at the home. One person told me, “The staff are very good”. Staff told me they were happy working at the home and staff turnover is low. This benefits residents and ensures a consistent approach to care provision. Well over 50 of staff have undertaken NVQ level 2 or equivalent and staff told me that training is given a high priority at the home, which they appreciated. Training certificates displayed in the home and contained in staff files indicated that staff have received the training they need to carry out their tasks and support residents effectively. Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 16 Staff files examined indicated that an appropriate recruitment process had been followed including the completion of application forms, interviews, taking up of references and pursuing Criminal Records Bureau checks. A recommendation has been issued that references obtained for new staff should include a company stamp or letter headed paper to further evidence their authenticity. One staff member had provided her own CRB disclosure during the recruitment process and the manager was reminded that all CRB disclosures must detail the name of the home where the staff member is working. This appeared to be a genuine misunderstanding and the manager told me she would deal with this issue as a matter of urgency. Staff files have now been indexed to facilitate ease of information retrieval. This was a recommendation from the last inspection. Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are promoted and protected. EVIDENCE: The manager, Tracy Simcox has been the manager for several years. She is has completed the Registered Managers Award training and is also a qualified nurse. Visitors, staff and residents I spoke with were very positive about the manager, one resident described the manager as, “Very helpful” and another told me, “She’s charming”. People were positive about the home and one Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 18 person commented that the home is, “Very well run”. Visitors and residents were also positive about the owners of the home, who have a very “hands on” approach. One visitor said, “I’ve never known people that own the home to be so caring”. This “hands on” approach of the registered providers means that they have a great deal of direct contact with residents and their visitors and so can respond to suggestions from residents about how to improve the service. The owners of the home were able to give practical examples of how the service has changed as a result of residents’ suggestions. This is good practice however a more formal approach to quality assurance is needed including a system to monitor how well the home is meeting it’s stated aims and objectives. Results of these quality monitoring surveys should be collated, summarised, published and made available to residents, their representatives as well as prospective residents to the home. A requirement relating to this has been issued in the relevant section of this report. The home holds small amounts of money on behalf of a few residents but generally invoices are sent to residents or their family every three months. A sample of these invoices were examined and found to be accurate and contained clear audit trails with appropriate receipts. Safety certificates were seen for the fire alarm, lift, hoist maintenance, gas safety and electrical installation. A health and safety policy was available as well as COSSH assessments. Records examined in relation to fire safety and accidents were satisfactory. The owner of the home told me that a fire drill was due soon. Currently fire drills take place during the day when night staff are working day shifts. A recommendation has been issued that some fire drills take place during the evening so that staff at night are aware of the proper procedures. This does not need to involve setting the fire alarm off as this could disturb residents. There were no safety hazards seen at the time of inspection. Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 19 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 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 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 3 Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 20 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 OP33 Regulation 24(2) The registered person must ensure that the results of any quality assurance surveys are published and made available to all interested parties. This includes residents and potential residents to the home. Requirement Timescale for action 01/12/07 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. 2. 3 Refer to Standard OP7 OP29 OP38 Good Practice Recommendations The registered person should ensure that the views of residents are sought every time care plans are reviewed. The registered person should ensure that references for all new staff include a company stamp or letter headed paper to further evidence their authenticity. The registered person should ensure that some fire drills take place at night so that all staff are aware of the appropriate night procedures. DS0000010571.V344221.R01.S.doc Version 5.2 Page 21 Hollies, The Hollies, The DS0000010571.V344221.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V344221.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. 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!