Inspection on 23/04/07 for Hollymead House

This inspection was carried out on 23rd April 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

Hollymead House 07/11/05

Hollymead House 19/07/05

Hollymead House 25/11/04

Hollymead House 23/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hollymead House 3 Downview Road Felpham Bognor Regis West Sussex PO22 8HG Lead Inspector Ms B Tye Unannounced Inspection 23rd April 2007 10:00 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 Hollymead House DS0000014572.V332938.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. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollymead House Address 3 Downview Road Felpham Bognor Regis West Sussex PO22 8HG 01243 868826 01243 870274 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) Mr Hugh Richard Reid Martin Mr Michael James Martin, Mrs June Catherine Martin Mr Michael James Martin Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users in the category Old age not falling within any other category (OP) only may be accommodated. Thirty five service users in total may be accommodated. One service user aged between sixty to sixty five years may be accommodated. 7th November 2005 Date of last inspection Brief Description of the Service: Hollymead House is a privately owned care home registered to accommodate up to thirty-four older people and one person under the age of sixty-five. The home is situated within the village of Felpham and is close to local shops and amenities. Accommodation is provided within thirty-three single rooms and one shared room over two floors with a vertical lift providing access. The home has several communal areas and a well maintained easily accessible garden. The registered manager is Mr Michael Martin and the registered owner is Mr H Martin. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection all relevant information and correspondence relating to the home was examined. This included correspondence, regulation 26 reports completed by the manager and notifications of significant incidents within the home. During the course of the inspection the inspector spoke to some of the people living in the home, a visiting relative, interviewed staff and spoke at length to the manager. All feedback received through out the visit reflected the residents were very happy with the standard of care they received and were encouraged to voice their opinions on the way the home is run. A tour of the premises was undertaken. The inspector observed lunch being served, medication being dispensed and staff interaction with residents. Five care plans and staff personnel files were examined alongside the homes records including, staff training and supervision, fire, incident and accident reports and all records relating to health and safety. This is the first inspection of 2006/2007. This is called a key inspection and will determine the frequency of visits/inspections hereafter What the service does well: What has improved since the last inspection? A previous requirement to introduce a suggestions box has been met and this is in place. A new staff induction handbook has been introduced and this is now completed with each new staff member on commencement of their employment. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Hollymead House DS0000014572.V332938.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 Hollymead House DS0000014572.V332938.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): Quality in this outcome area is good. Prospective residents and their families can be confident that current information regarding the home will be made available, their needs will be assessed and visits to the home encouraged. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is sufficient information in the Statement of Purpose and Service User Guide to ensure that prospective service users and their families are enabled to make an informed choice about the services provided in the home. Pre-admission assessments are carried out prior to admission. These have not been retained, as all information is transferred to residents on-going care plans. It was recommended that the manager keep all completed admission records on file for reference. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 9 Each resident receives a contract of terms and conditions of residency, signed by them or their representative Hollymead House does not offer intermediate care. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. All residents have a comprehensive care plan and risk assessments in place. These are reviewed and updated on a regular basis. Medication procedures are in place and staff receive medication training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a care plan in place for each person living in the home and information is reviewed and updated by the manager on a monthly basis. It was recommended as a matter of good practice that the residents sign completed care plans and monthly reviews. The care plans include assessments of health and social need, risk assessments and personal routines. The layout is well ordered to easily inform new staff members about the personal and health details of the people they are supporting. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 11 The members of staff spoken to show an awareness of the support needs of residents. Any changes in the care plans are communicated at shift handover times and through the daily recording system. Residents confirmed that their rights to dignity and privacy are upheld by the staff at the home. In relation to health and personal care needs, observation and feedback from residents reflect that they are treated with respect by staff, and their privacy and dignity is upheld. Any specialist health needs are referred to community-based professionals via the GP’s. Correspondence held in individual files supported this. A Chiropodist visits the home on a six weekly basis. Staff undertake medication training. The home has an up to date policy, procedure and code of practice relating to dispensing medication. Medication charts and storage of medicines within the home were examined. These were generally in good order, demonstrating the staff adhered to the procedures within the home. Where possible residents are supported to manage their own medication. Signed medication consent forms and monthly medication reviews, support this practice. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are supported to make choices where possible. Residents said their families/visitors were made to feel welcome. The mealtimes are well managed. Meals are nutritionally balanced and varied according to dietary requirements and preference. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents visitors are welcomed to the home and feedback from residents confirmed that contact with family and friends is encouraged. Activities are organised at the home on a regular basis, offering stimulation to those residents who are less able to explore interests outside the home. Religious needs are detailed on care plans. Forthcoming activities and events are displayed on the community pin board in the home. A cardex system, details which residents participate in which activities, on a daily basis. Staff were observed chatting with some of the residents and the interaction between them was relaxed and respectful. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 13 Residents have the opportunity to attend weekly residents surgeries, where they can feedback to a senior resident and make suggestions about issues as they arise. A suggestion box is also in place to enable residents to contribute to the way the home is run. Menus show that a variety of fresh, home cooked meals are available and residents have their nutritional needs assessed as part of care planning. Special diets such as diabetic and pureed meals are available. Residents who need pureed food have this blended separately to look attractive. A resident said, “ The meals are wonderful, there is always choice and plenty to eat”. All the food is home cooked on a daily basis by a qualified staff member. There is a large choice available to suit preferences of the residents. Each afternoon a tea is served, homemade cakes and biscuits are available to residents and their visitors. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Complaints are acted upon. Working practices and staff training are designed to protect residents from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place a copy of which is included in the Statement of Purpose and Service User Guide. The complaints book showed that there have been no complaints since the last inspection. Following a previous recommendation there is also a suggestion box within the home to encourage comments from residents and visitors. All staff have undertaken a full induction and Adult Protection training to ensure they respond appropriately to suspected abuse in the home. A copy of the West Sussex County Council Multi Disciplinary Adult protection Policy is kept in the office for reference. Staff members undertake mandatory training and have completed or are participating in training leading to a National Vocational Qualification Level 2. This promotes awareness of what constitutes bad practice. The procedures for the recruitment of staff are robust and provide the necessary safeguards to offer protection to the residents living in the home. All Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 15 care staff have undertaken a Criminal Records Bureau enhanced check to ensure they are suitable to work with vulnerable people. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. Residents live in a comfortable and homely environment and have access to communal facilities. Standards of hygiene and cleanliness are maintained throughout the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following a tour of the premises and examination of health and safety records it is evident the home provides a homely, well-maintained and safe environment. Standards of hygiene and cleanliness are well maintained throughout the home. Use of gloves, aprons and colour-coded bins was observed. This minimises the spread of infection in the home. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 17 Residents are encouraged to move around the home and have access to the dining room and the lounges/conservatories throughout the day. Residents were observed socialising in these areas during the visit. Residents’ rooms were attractively presented. Several rooms were visited by the Inspector to ensure that the environment was safe and comfortable, all stated how pleased they were with their bedrooms. Bedrooms were furnished with personal possessions and the option is given to bring furniture from home, giving each resident a sense of ownership in their private space. There is a passenger lift for residents with limited mobility to access all floors of the house. Provision of a bath hoists, grab rails and raised seating in toilets provide individuals with limited mobility more independence. A call bell is provided in every room so staff are aware and can attend an emergency situation should it arise. There are sufficient toilets and assisted baths with thermostatic valves to protect residents from scalding water temperatures. Radiators are guarded and the home was clean and hygienic throughout. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. A caring and well-trained staff team supports residents in the home. Recruitment records are in good order. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas showed an adequate number of staff are on duty at all times. A senior staff member leads each shift. Domestic staff are employed in sufficient numbers to ensure that the standards relating to good food and cleanliness are adhered to. This minimises the spread of infection within the home. Staff members, who were spoken with in private, said that they found the manager to be ‘supportive and helpful’. All commented the, ‘team worked really well together’. Each staff member has training certificates on file and there is evidence that a variety of courses are undertaken including medication, first aid, manual handling and the protection of vulnerable adults from abuse. The recruitment files of five staff members were seen and all contained the required documentation including CRB checks. Recruitment to the home is Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 19 supported by policies and procedures, which include practice of equality and diversity. The people on duty were kind and caring in their dealings with residents and were seen offering choice and supporting people to be as independent as possible. The people living in the home said that the staff team were kind and caring, one person said, “The staff here aren’t bossy, we can do what we like. They look after us very well’. Staff spoken to are clear about their roles and responsibilities. They confirmed the manager of the home was supportive and they attended regular team meetings to discuss practice issues. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. The registered manager is qualified and experienced to manage the home and is actively involved in the care of residents. The home is run in the best interests of the residents whose health, safety and welfare is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector examined record keeping for all aspects of health and safety, risk assessments and policies. Those seen were in good order and up to date. This practice ensures the occupants of the home are safeguarded and protected. Staff feedback reflected that the manager provides good leadership and direction. Staff spoken to stated he was ‘supportive and approachable’, Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 21 enabling them to seek guidance as it was needed, to ensure residents needs were met appropriately. Staff spoken to stated they received regular supervision and support from the manager. Records were evidenced on staff files detailing regular supervision sessions at two monthly intervals. Regular staff meetings and weekly residents surgeries allow participants of the home to be kept up to date with changes and enables them to give their views about how the home is run. Policies and procedures are in place and kept up to date in line with changing legislation. The home has insurance cover is in place and there is a business and financial plan for the home, which would be available upon request. Residents’ finances are protected by policies, procedures and record keeping. Residents have their own bank accounts and all financial transactions are recorded and signed for by the manager. As a matter of good practice it was recommended that the residents should also sign records when any financial transaction is undertaken. An annual quality assurance report is underway, which includes contributions from service users and their families. As yet this information has not been collated and published but feedback questionnaires from residents and their families have been completed. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 22 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 3 X 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 3 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 3 3 X 3 3 Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 23 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. 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. 2. 3. Refer to Standard OP35 OP7 OP4 Good Practice Recommendations It is recommended that the residents sign for all financial transactions It is recommended that the residents at the home sign their completed care plans and on going monthly review It is recommended that the residents pre-admission assessments are retain by the home. Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Hollymead House DS0000014572.V332938.R01.S.doc Version 5.2 Page 25 - 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. 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