Inspection on 11/07/05 for Hollybush Care Home

This inspection was carried out on 11th July 2005.

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

Hollybush Care Home 26/07/06

Hollybush Care Home 21/03/06

Hollybush Care Home 09/03/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Hollybush 101 Lovely Lane Warrington Cheshire WA5 1TY Lead Inspector Paul Ramsden Announced 11 July 2005 9:30 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 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. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hollybush Address 101 Lovely Lane Warrington Cheshire WA5 1TY 01925 631605 01925 631605 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Adebunmi Oseni Mrs Joyce Sharp Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for a maximum of 15 service users in the category of OP (Old age, not falling within any other category) 2 The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Date of last inspection 15/03/05 Brief Description of the Service: Hollybush is a three-storey privately owned care home standing in its own grounds, access between floors is via a shaft lift or the stairs. Residents are accommodated on the ground and first floors only. Personal care and accommodation is provided for fifteen older people aged sixty-five years or over. The home is located in Lovely Lane and is within easy walking distance of a range of local shops and amenities. Warrington town centre is a short bus journey away and the home is near Warrington General Hospital. There are adequate car parking facilities available at the home. Residents accommodation consists of eleven single bedrooms, and two twin bedded rooms. The home has adequate recreational, dining and communal space available within the building for the number of service users that can be accommodated. Hollybush has an adequate number of toilets and a variety of bathrooms available for service users.There is an enclosed garden with sitting areas to the side of the home. This is accessible and well maintained. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out on 11 July 2005 and lasted approximately five and a half hours. The registered provider and home manager were on duty together with the agreed numbers of care and ancillary staff. Fourteen people were living in the home at the time of the inspection. During the inspection ten residents, a community nurse, a visiting relative, the registered provider, the manager and three of the staff on duty were spoken with. A range of care, health and home records were examined and a tour of the premises, including all communal areas and a number of bedrooms, was undertaken. Comment cards for use by residents and relatives were forwarded to the home prior to the inspection. In addition cards for GP’s and care managers in contact with the home were sent out. Four resident, two relative, three GP and one-care manager cards have been returned to the CSCI. The registered provider and home manager are currently updating the home’s policies and procedures. What the service does well: Residents, the visiting relative and the community nurse spoken with made a number of positive comments regarding the care and services provided at Hollybush. The home manager said that the staff members were settled and friendly and wanted to provide a good standard of care to the residents that live at Hollybush. The comment cards received contained a number of positive comments about the home. One of the relatives has written, “Hollybush is an excellent home from home”. Good relationships were seen to exist between residents and staff and all of the residents said that the staff members were good. Residents considered that routines within the home were flexible and that this gave them some control over their lives and enabled them to be more independent. A variety of activities/social events are provided. Catering within the home appeared to be well managed and all residents said the food was good. They also said that they were offered choices at mealtimes. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 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 standard(s) 1 and 3 A new statement of purpose and service user guide is now available. Residents are assessed prior to admission to ensure that the home will be able to meet their needs. EVIDENCE: The registered provider and home manager have updated the statement of purpose and service users’ guide. As part of the inspection process the care files of two people living at the home were reviewed. Pre-admission assessments that demonstrated that resident’s individual needs were being assessed in an accurate and consistent way had been carried out. Those seen contained enough information for staff to be able to meet individual needs. Residents, relatives and other healthcare professionals are involved with the pre-admission assessment. Various risk assessments were also completed. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10 All residents have a care plan that shows how their individual needs are being met. The health, social and emotional needs of people living at Hollybush are being identified and met. EVIDENCE: The home manager or deputy is responsible for drawing up a resident’s plan of care. A discussion about the new care plans that are being implemented was held with the registered provider and manager, a number of amendments were suggested. These will be looked at again during the next inspection. The two care plans seen as part of the case tracking process provided staff members with the necessary information for them to look after a person’s needs. There was written evidence to confirm that care plans were being reviewed and that residents or their families/advocates were being consulted about there content. The GP and care manager comment cards received contained a number of positive opinions about the home. The visiting community nurse said that the quality of care provided to her patients was of a very good standard. All personal care is carried out in the privacy of a resident’s bedroom or one of the bathrooms. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13, 14 and 15 Routines at the home are flexible to suit residents’ individual preferences. The food provided to residents is of a good quality. EVIDENCE: Residents confirmed that routines within the home were flexible and that they were able to make choices in many areas of daily living, for example times of rising and retiring, where to spend time and with whom. Staff members were observed to knock on the door and to await permission before entering a resident’s bedroom. Comments made by residents during the inspection included “My family looked at other homes but Hollybush was the best” “the staff are very good”. All of the residents spoke positively about the care provided to them. The visiting family member said that she thought Hollybush was very good and her mum was being well looked after. The four resident, completed with staff assistance and two relative comment cards received also contained positive comments about Hollybush, these included, “Hollybush is an excellent home from home”. Meals can be taken in the dining room or in the privacy of residents’ own rooms. The kitchen area was well managed and organised. Since the last inspection visit a new menu has been introduced, this has the flexibility to Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 11 meet individual needs and choices. All of the residents that commented said that the food was good and that choices were available. Special diets are prepared where necessary. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16 and 18 Residents are able to voice their opinions and are confident that appropriate action would be taken to address any problems or complaints. Policies, procedures and staff training are in place to protect residents from abuse. EVIDENCE: There is a written complaints procedure for the home, this is displayed in the main reception area; this is also included in the Statement of Purpose and Service User Guide. Residents were aware of their right to complain if they were unhappy with any aspect of the service they received at Hollybush. The home has an Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the Department of Health Guidance, No Secrets. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19 The home provides adequate facilities to meet the needs of older people. Standards of hygiene and cleanliness are good. EVIDENCE: A tour of the premises was undertaken; this included communal areas and a number of bedrooms. The home both externally and internally is maintained to a good standard. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28 Staff members were seen to be working positively with residents, families and visiting professionals to improve the quality of life of people living in the home. The implementation of a new smoking policy has caused unrest among some staff members. EVIDENCE: Staff on duty and rotas seen demonstrated that staffing levels and the skill mix of staff were adequate to meet the needs of the residents within the home. The staff members seen on the day were cheerful and friendly and residents were complimentary about staff attitude and competence. The registered provider and home manager explained that they were currently dealing with a staff issue that could affect the home’s ability to maintain the agreed staffing levels. Some of the staff members were refusing to cover extra shifts due to the implementation of a new smoking policy. It was agreed that the CSCI would be kept fully informed regarding this matter. The home manager has confirmed that the home has in excess of 50 of staff qualified to NVQ level 2. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 and 38 The home is being well run and managed on a day-to-day basis. EVIDENCE: The home has an experienced and competent manager who is registered with the Commission for Social Care Inspection. The residents, family member and visiting community nurse that commented said that the home manager was approachable and supportive. A quality assurance survey to ascertain whether residents and families are happy with the standards of care being provided is to be undertaken in August and September. Copies of the results will be made available to residents, families and the Commission. There is a suggestions box in the entrance area. All staff members are supervised on a continuous basis; in addition they will all receive formal supervision regularly. There was evidence that staff were Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 16 receiving training in areas such as moving and handling, first aid and fire safety. The fire precautions record book was up to date and demonstrated that checks of the alarm system, emergency lighting, fire drills and staff training were taking place. Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x 3 x 3 Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 18 No 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations Hollybush F51 F01 S62759 Hollybush V230717 110705 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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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