Inspection on 17/01/06 for Holly House

This inspection was carried out on 17th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holly House 30/10/06

Holly House 24/08/05

Holly House 21/01/05

Holly House 06/09/04

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 Holly House 24 Queen Anne`s Place Enfield Middlesex EN1 2PT Lead Inspector Tom McKervey Unannounced Inspection 17th January 2006 09:00 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 Holly House DS0000010640.V265666.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. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly House Address 24 Queen Anne`s Place Enfield Middlesex EN1 2PT 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 8360 7622 020 8360 7622 hollandsepping@ntlworld.com Mr J N Holland Mrs Mary Alexandra Holland Mrs Ellen Mary Willcox Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2005 Brief Description of the Service: Holly House is a privately run care home owned by Mr and Mrs Holland. The registered manager of the service is Mrs Eileen Wilcox. The home provides personal care and support for 16 older people of both genders. The home is in a large three-storey detached building, situated in a tree-lined avenue in the pleasant residential area of Bush Hill Park, near Enfield. There are shops and a post office nearby and there are good public transport links to the area. The home has 12 single bedrooms and 2 shared rooms on three floors, all individually decorated. On the ground floor, there is a lounge and separate dining room. A lift provides access to the upper floors. A paved area at the front of the building provides some car parking. There is a large conservatory and an attractive garden at the rear of the premises. The home aims to provide a high quality of personal care and support for people who are over 65 years of age. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of five hours. Both proprietors and the registered manager were present. The inspection process consisted of speaking to eight residents, five relatives, and four staff. A district nurse who was attending to a resident at the time of the inspection, was also interviewed. The comments about the quality of care were very positive, and no concerns were raised by the residents, relatives or staff. Residents’ case files, staff records, and documents relating to the running of the home were also examined during the inspection. What the service does well: What has improved since the last inspection? Residents’ care plans are drawn up in consultation with the resident, and/or their representatives. A new shower for disabled residents has been installed, and new carpet has been laid in various areas in the home. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 6 One bedroom and a communal toilet have been completely refurbished and new bedroom furniture provided. Staff have attended training in adult protection procedures. All maintenance issues identified at the last inspection have been addressed satisfactorily. 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. Holly House DS0000010640.V265666.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 Holly House DS0000010640.V265666.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): 2, 3, 4, & 5 Standard 6 does not apply. The residents said that the quality of the service provided was very good and meets their needs. Prospective service users are able to experience the facilities and talk to residents to enable them to judge the suitability of the home. EVIDENCE: The proprietor expressed a concern regarding a resident who had originally been admitted for a trial period, but who, nine weeks later, had not been assessed by their social worker, despite several request being made. This resulted in no funding being provided for this resident. At the time of writing this report, the inspector was informed that this matter was now resolved. Two other residents’ case files were examined. There was evidence that service users had been needs-assessed before admission to the home. Residents and visitors who were spoken to, said that service users’ needs were being met very well and that the staff were very caring. They also said that they had visited the home prior to moving in. During the inspection, a gentleman arrived at the home to spend the day to assess whether he would like to move in. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 9 Holly House DS0000010640.V265666.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 & 10 The residents’ healthcare needs are being met by appointments with various health professionals, and they are treated with respect and dignity by the staff. Medication is stored and administered safely. EVIDENCE: Four residents’ care plans were examined. The care plans were reviewed monthly. The plans included risk assessments, covering areas such as moving and handling, and the risk of falls for residents with mobility problems. Annual reviews by placing authorities were carried out. In some cases, the care plans had been signed by the resident or their representative. There were records of a variety of healthcare appointments being attended by residents; for example, hospital out-patients, the G.P, optical and dental services. At the time of the inspection, the district nurse visited to change a resident’s dressing. The storage and administration of medicines was checked and was found to be in order. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 11 Residents and relatives spoke very highly of the staff and managers. The residents said that they were always treated with respect and dignity and were spoken to by their preferred mode of address, and that personal care was given in a discreet manner. Holly House DS0000010640.V265666.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 & 15 There is insufficient evidence to show that residents are provided with activities that are stimulating and comply with their individual wishes. Residents’ meetings are held regularly which enable them to express their views about the service. The residents are very happy with the food provided by the home. EVIDENCE: At the last inspection, a requirement was made for an activities programme to be provided. The inspector was shown an activities timetable for each day of the week, and it was evident that the proprietors were trying to improve this area of the service. However, in discussing this issue with the proprietors, it was evident that the programme was not a true reflection of the reality on a daily basis. The inspector discussed the issue of activities with several residents, and there was a mixed response, ranging from being happy with just reading or watching television, to wanting more stimulating activities. However, none of the residents were very specific about these. It was noted that some organised activities were happening, such as “music and movement” sessions and bingo. Also, an outside person provides entertainment sessions every few weeks. Birthdays are celebrated and some residents go out shopping. Staff also spend time with the female residents, doing their nails. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 13 Very few of these activities were being recorded in residents’ records. A requirement is made to consult with individual residents about providing stimulating activities, which are specific to that resident’s wishes, and to record activities in residents’ progress records as evidence. Relatives confirmed that they could visit at any time and there were few restrictions on visitors. Regular meetings are held with the residents and staff as a way of encouraging them to make decisions regarding the running of the home. An inspection of the kitchen showed that there was plenty of food available and that it was safely stored. The menu contained a good variety of meals and was balanced and nutritious. The residents said that they were consulted about the menu and there was always an alternative option available, including vegetarian dishes. Fresh fruit was also available. The inspector observed lunch being served. It was hot and attractively presented. Holly House DS0000010640.V265666.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): 16 & 18 The residents’ welfare and best interests are safeguarded by appropriate complaints systems and staff training about protection of service users from harm. EVIDENCE: There is an appropriate complaints procedure in place. No complaints had been made about the home since the last inspection. Residents and relatives who were spoken to, said that they were very satisfied with the service and were able to describe the process whereby they would raise any concerns. Since the last inspection, the staff had attended training in adult protection. In discussion with the inspector, the staff demonstrated a thorough knowledge about issues of elder abuse and how to report these matters. Holly House DS0000010640.V265666.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, 21, 23 & 26 Residents live in a very attractive and comfortable home that is generally well maintained. Two maintenance issues have been identified, which if not addressed, could affect residents’ safety. EVIDENCE: A tour of the premises showed that the home was very well maintained and there was a high standard of décor throughout. Several bedrooms were seen, and they were very attractively furnished and decorated. New carpets had been laid recently on stairs and some bedrooms. However, one bedroom door did not close due to the new carpet. The water in several toilet and bathroom outlets was very hot. It was noted that there were no bath thermometers. These must be obtained to prevent the risk of scalding. Requirements are made to address these issues. Maintenance issues identified at the last inspection had all been attended to. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 16 At the time of the inspection, the home was very clean and tidy and there were no offensive odours. Holly House DS0000010640.V265666.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): 27, 28, 29 & 30 There are sufficient numbers of staff on duty and they are well trained to meet residents’ needs. However, staff recruitment procedures must be improved in order to safeguard residents from potential harm. EVIDENCE: The staff rota showed that there were sufficient numbers of staff on duty at all times to meet the residents’ needs. The records of two recently recruited staff were examined. References had been obtained, but in one instance, although an application for a Criminal Records Bureau check had been made, this had not been obtained before the carer had started work. An immediate requirement was made for a Protection of Vulnerable Adults check to be carried out while waiting for the CRB certificate. There was evidence of training in the mandatory subjects and adult protection. At the time of the inspection, six staff had attained National Vocational Qualification level 2, and another carer was soon to begin NVQ level 3. Holly House DS0000010640.V265666.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): 32, 36 & 38 This home is well managed and there is a relaxed and friendly atmosphere. Staff receive regular supervision to support and monitor their duties as carers. The health and safety of residents is generally safeguarded, however the hot water temperature must be monitored to further protect residents from the danger of scalding. EVIDENCE: Through discussions with residents, visitors and staff, and also observing various interactions between these persons and the management, it was apparent that the home was managed in a relaxed and business-like manner. Staff records showed that they received regular, formal supervision. The home had recently had an inspection from the Environmental Health officer and had received a good report. The fire log showed that alarms were tested regularly and drills were carried out. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 19 As noted under Standard 19, the hot water temperature must be monitored and a bedroom door must be repaired as health and safety issues. Holly House DS0000010640.V265666.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 X 3 3 3 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X 3 X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 X X X 3 X 2 Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? 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 OP12 Regulation 16(2)(m)( n) Requirement Timescale for action 31/03/06 2.. OP19OP21 23 (2)(b) 3. Op29 7, 9, 19 Sch 2 & 4 4. OP19OP38 13(4)(c) The registered persons must ensure that service users are consulted regarding their social interests. An activtities timetable based on service users needs and preferences must be available. This requirement is restated from the last inspection. The previous timescale was 11/11/05 The Registered Manager must 31/03/06 ensure that the door of a resident’s bedroom can open and close freely. The Registered Manager must 18/01/06 ensure that no member of staff works at the home before obtaining a CRB clearance. This is an immediate requirement. The Registered Manager must 31/03/06 ensure that bath thermometers are provided and the hot water temperature is monitored to ensure it does not exceed 43ºC. Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 22 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 Holly House DS0000010640.V265666.R01.S.doc Version 5.0 Page 23 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. 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