Inspection on 17/07/06 for Hollywell Court

This inspection was carried out on 17th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Hollywell Court 27/09/05

Hollywell Court 20/04/05

Hollywell Court 11/01/05

Hollywell Court 17/05/04

Hollywell Court 24/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Hollywell Court 464 London Road Leicester Leicestershire LE2 2PP Lead Inspector Thea Richards Unannounced Inspection 17th July 2006 09:30 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 Hollywell Court DS0000006384.V304114.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. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollywell Court Address 464 London Road Leicester Leicestershire LE2 2PP 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) 0116 2702252 0116 2702252 Hollywell Care Limited Mrs Carole Garrity Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration.. Date of last inspection 27th September 2005 Brief Description of the Service: Hollywell Court is registered to care for twelve older people in a large converted property. It is situated on London Road close to the town centre of Oadby, where residents have access to a variety of amenities and it is on a bus route into Leicester city centre. The premises consist of two floors, with access to the first floor by use of the passenger lift or stairs. The home has eight single bedrooms, five with ensuite facilities and three with hand washing facilities in a vanity unit. The two, shared bedrooms both have en-suite facilities. There are sufficient toilet and bathroom facilities on both floors for the residents who are to be accommodated. The home has a well- maintained garden and patio area to the rear of the premises for the use of the residents. There is information available in the reception area including the Registration certificate. The latest copy of the Inspection report from the Commission for Social Care Inspection is available to view in the managers’ office. The current fee level ranges from £ 350.00 to £ 550.00 p.w. There are additional costs for individual expenses such as personal toiletries, optician, hairdressing and some recreational activities Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of the home that was concluded with an unannounced visit to the home. Prior to the visit the inspector spent a day reviewing the previous inspection report and information relating to the home received since the last inspection on the 27th of September 2005. The visit took place on the 17th July 2006 from 10.15 and lasted five hours. During the course of the visit the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that the inspector looked at the care provided to two residents living at the home, by talking to the residents themselves; talking with staff supporting their care; checking their records relating to their health and welfare; viewing their personal accommodation (with their consent) as well as communal living areas. The inspector also checked other issues relating to the running of the home including health and safety, management and staffing areas. During the visit the inspector spoke with other residents in the home, staff, a visitor and the manager. The inspector also observed care practices when staff assisted residents. What the service does well: What has improved since the last inspection? The residents’ care plans are now available to the staff to access, which allows them to keep updated with the residents needs. Hollywell Court DS0000006384.V304114.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. Hollywell Court DS0000006384.V304114.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 Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using the available evidence. Residents’ needs are well assessed prior to moving into the home by the completion of a pre-admission assessment by a trained member of staff or by Social Services. EVIDENCE: The inspector checked the care records of two residents who were case tracked. All residents have a contract and a statement of terms present in in their files. Completed pre-admission assessments are present in the residents files, identifying their needs, prior to their admission to the home. Care plans reflected the needs of the resident identified in the pre-admission assessment. Staff spoken with said that they were aware of the residents needs prior to them moving into the home. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The staff fully meet the care needs of the residents. EVIDENCE: Care plans for two residents were ‘case tracked and found to contain good individual evidence of care, which reflects the care being given to the residents. There is evidence of the involvement of G.P.s, district nurses, chiropodist, optician and dentist. The daily record of care was found to be up to date. Care plans identified the residents care needs and there was evidence of them having been updated which ensures that the staff are kept aware of the residents’ current needs. Staff spoken with were aware of the care needs of the residents. Medication records for the case tracked residents were in order. Staff were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. Medicines are dispensed using a ‘Nomad’ system which is filled by the pharmacist. The pharmacist who supplies the home used to complete six monthly audits, which were satisfactory, but no longer has a requirement to do Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 10 so and has therefore stopped. There are no residents currently administering their own medication. The inspector observed the residents being treated with dignity and respect when the staff spoke with them, assisted them at lunchtime and provided care. The residents spoken with were happy with the way staff treated them and said that they were very kind. An incident with a member of staff, had the previous week been managed correctly and effectively. A visitor spoken with on the day of the visit was very happy with the level of care being given, he had had the opportunity of visiting the home prior to his relative being admitted and had a visit from the manager from the home. He was aware of the procedure to follow if they had a complaint or concern and would have no anxiety in doing so. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome group is good. This judgement is made using available evidence including a visit to the service. Residents have their social, religious and nutritional needs met. EVIDENCE: There was little documentation available in the residents care plans to indicate that they were taking part in activities in the home. The residents confirmed that they enjoyed the activities and took part in them, this should be documented in their records. There is not a dedicated activities organiser in post, but the manager and the staff are all involved in any activities. There is a regular programme of activities arranged and a weekly programme is published on a ‘white board’ in the lounge. On the day of the visit there was no organised activity observed by the inspector but good individual interaction between the staff and residents was seen. On the day of the visit residents were observed sitting in a choice of two lounges talking and listening to music. Residents spoken with told the inspector they enjoyed the activities that were provided, but equally, enjoyed sitting and chatting to the other residents and having the opportunity to read and watch some television. Entertainment such as ‘The Musicman, who comes into the home fortnightly is provided, together with bingo, board games and chess. There are outings arranged locally into Oadby town centre, Leicester city centre and to a garden centre. An aromatherapist visits the home fortnightly as does the hairdresser, some residents have their own hairdresser who is also able to Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 12 visit. The residents have individual access to their own clergy who are able to visit the home and see them privately. There is a choice of meals available and diabetic meals are provided; if there was a need for diets such as vegetarian, the home would be able to provide them. Residents spoken with all said that they enjoyed the food and were very happy with the choices. On the day of the visit, which was extremely hot, the inspector observed frequent drinks being given to the residents. The residents were observed enjoying their lunch and the inspector talked to them during it and they said that the food was excellent. There was a choice of chicken casserole or lasagne served with a variety of vegetables or salad followed by a choice of several sweets. Visitors are made welcome in the home and mainly visit at weekends, some take their relatives out regularly. This was confirmed by a visitor spoken with, who told the inspector that they were made very welcome at any time. Families and friends are asked their views about the home and they have recently had a quality survey sent to them to gain their opinions. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. There are systems in place to support and protect residents and staff are knowlegeable about the processes. EVIDENCE: There is a complaints policy in place and no complaints or concerns have been recorded in the home since the last inspection. Residents spoken with were happy that they would speak to the manager or a member of staff, if they had a need to. A visitor spoken with on the day of the visit said that if he had any concerns he would speak with the manager who would resolve it and that he was aware of the procedure to complain and would have no concerns about doing so. The Commission for Social Care Inspection has received no complaints or concerns since the last inspection. There were no professional staff visiting the home on the day of the visit. The staff have received training in ‘Safeguarding Adults’ and the staff spoken with were knowledgeable about the process and would be prepared to ‘whistle blow’ if they felt that they needed to. However, this training is not up to date and both the manager and the staff should receive updated training to ensure that the residents are fully protected. A notification (Regulation 37) for an accident resulting in a resident being sent to hospital had been sent to the Commission For Social Care Inspection, but there was no record held in the accident book which means that there is no Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 14 record held in the home, therefore the home would be unable to audit their accident records accurately. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 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, 20, 23, 24, 25, 26 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents live in a generally good and safe environment. EVIDENCE: The registration certificate from the Commission for Social Care Inspection was displayed in the reception area. The communal areas including the lounges and dining room provide a homely and comfortable environment for the residents to live in. The home smelt clean and fresh in all areas. The manager told the inspector that the stair carpet was to be renewed as it was quite worn and could present a ‘trip’ hazard if it deteriorated much further. A bathroom contained unamed toiletries on a shelf which was identified to the manager as an infection control risk if used by several residents, the manager said that she would have them removed. With their permission, the bedrooms of the ‘case tracked’ residents were looked at. The bedrooms provided good accommodation and had been personalised with the resident’s belongings. They were clean and safe and had en-suite facilities of a W.C. and wash hand Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 16 basin. There were no outstanding safety or maintenance issues noted on the tour of the premises. Records for the maintenance of fire equipment, fire-drills and testing of water temperatures were found to be in order. An environmental health visit had been made six months previously and everything was found to be in order. There had been a visit from the fire officer who had found everything in order and had advised the manager on the use of door closers. There is level access to well kept grounds which enables the residents to spend time outdoors if they wish. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 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 Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The residents’ needs are met and their safety protected by the staff. EVIDENCE: There is evidence of a good skill mix of staff to give the care identified for the residents needs and the number of staff on duty reflected the duty rota. The residents, the staff and the visitor spoken with felt that there were always sufficient numbers of staff on duty to cater for their needs. Two staff files were viewed by the inspector and the required documentation was complete in both files, including identification, two references, an application form and a Criminal records bureau check. There was evidence of a robust recruitment policy in place which ensures the safety of the residents. There was evidence of staff training in the files and staff spoken with, confirmed that they received regular training including induction training, which ensures that the residents have their care needs met. The staff have received training in basic food hygiene, dementia awareness, first aid, the care of pressure sores and catheter care. There are currently no staff with a National Vocational Qualification in care at level two or above but nine staff are about to begin it. The National Vocational Qualification is a qualification for care staff to ensure that they receive appropriate training in the needs of the resident group which they are caring for. The manager has completed a National Vocational Qualification in Care at level four. There was evidence in place that staff supervision was in place which gives staff time with their line manager to discuss their work and training needs. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 18 Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 38 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents live in a home, which provides for their needs, with basic safety and protection in place. EVIDENCE: The manager was available throughout the visit to the home. The manager has worked in the home for eight years. She has completed a National Vocational Qualification in care at level four which enables her to ensure that the correct care is delivered to the residents. The manager holds regular meetings with the residents and has one to one discussions with them and their families to ensure that the home is providing the service that they need and require. She follows residents’ meetings with a meeting with the staff to discuss the content with them if appropriate and includes other issues which need communicating. A quality questionaire has been distributed to residents and families to gain their views. The manager spends time working with the staff to supervise them and to Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 20 ensure that the correct care is being given to the residents. Residents are protected by the recruitment policy, with the obtaining of relevant documentation such as references, identification and criminal records bureau checks. Staff were being given appropriate training to look after the residents both in care needs and health and safety issues. This was confirmed by available documentation and by staff spoken with. An incident report (Regulation 37) has been received by the Commission for Social Care Inspection for a residents’ transfer to hospital, but had not been entered into the accident book which would allow the manager to review accidents in the home more accurately. Residents’ finances are handled by their families with the home holding some monies on their behalf for incidental expenses. This is handled by the manager with good individual records in place, all transactions have two signatures. There are records of expenditure available in the home. Residents’ needs are met with a good working relationship with the district nurses, who will supply equipment for the use of the residents if it is needed. The homes owner supplies equipment if needed and provides both financial and physical resources for recreational activity. The home is supported by the National Health Services Intermediate care unit, which enables residents to remain in the home and receive care there, where possible, sooner than being transferred to hospital. There are appropriate records in place confirming that all health and safety requirements are being met, to maintain a safe environment for residents and staff. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 22 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 Refer to Standard OP18 Good Practice Recommendations The Registered Person should ensure that the training in Safeguarding Adults is up to date for herself and the staff. Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hollywell Court DS0000006384.V304114.R01.S.doc Version 5.2 Page 24 - 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!