Inspection on 11/12/07 for Hollywood Rest Home

This inspection was carried out on 11th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Hollywood Rest Home 18/11/08

Hollywood Rest Home 02/08/06

Hollywood Rest Home 12/01/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Hollywood Rest Home 791 Chester Road Erdington Birmingham West Midlands B24 0BX Lead Inspector Brenda O`Neill Key Unannounced Inspection 11th December 2007 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 Hollywood Rest Home DS0000065660.V355977.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. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollywood Rest Home Address 791 Chester Road Erdington Birmingham West Midlands B24 0BX 0121 350 6278 F/P 0121 350 6278 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) Hollywood Rest Home Ltd ****Post Vacant**** Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accommodate 25 service users who require care for reasons of old age plus 1 named service user who needs care for reasons of mental health problems (over 65 years), 25 in Hollywood main unit and 1 in Evelyn Court Unit for reasons of old age with a mental disorder. That the Evelyn Court unit is staffed separately by a minimum of 1 person when the service user is in the accommodation. 2nd August 2006 2. Date of last inspection Brief Description of the Service: Hollywood rest home is situated on the corner of Chester Road and Orphanage Road in a mainly residential area of Erdington. It is close to local shops, public houses and other community facilities. The home is within easy access of public transport and on the main bus route for convenient access to Erdington. Formerly a family home with an attached coach house, the property has been converted and extended to provide accommodation for 26 elderly people. Bedrooms are provided over two floors consisting of seventeen single and four double bedrooms several of which have en-suite facilities. Communal facilities are all on the ground floor and comprise of two comfortable lounges and a dining room. People living in the home also have access to another room known as the library, which provides a quiet sitting area when needed with toilet off. Bathrooms and toilets are located throughout the home and there is a shaft lift to the first floor ensuring people with mobility difficulties have easy access. Two of the bedrooms are accessed either by stairs or a stair lift for those with mobility difficulties. The registration for the home also includes a one bedroom flat next door to the main home. This was not occupied at the time of this inspection. The flat is self-contained comprising of a lounge, kitchen, one bedroom, toilet and bathroom. All the rooms are very large, well decorated and the furnishings and fittings are of a very high standard. Separate staff are allocated to provide support to the flat when it is occupied. There is parking to the side of the home to accommodate up to six cars. Further parking facilities are available adjacent to the home offering a further nine spaces. At the rear is a large well-maintained garden with garden furniture, patio, barbecue and an aviary. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 5 There was no information included in the service users guide about the range of fees charged at the home. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection over one day in December 2007. During the course of the inspection a tour of the home was carried out, the care for three of the people living in the home was tracked. One staff file was sampled as well as other staff training records, care and health and safety documentation. The inspector spoke with the acting manager, the new proprietors, two staff members and three of the people who live in the home. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently using a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes a person whose knowledge about social care services comes directly from using them. Prior to the inspection the acting manager had completed an Annual Quality Assurance Assessment which gave some additional information about the home. Ten surveys were sent out to the people living in the home and some of their relatives. Three of these were returned. The home had not had any complaints lodged with them since the last inspection. Some anonymous concerns had been raised with the Commission about the attitude of some of the staff. This was discussed with the acting manager. No evidence was found during the course of the inspection to support the concerns. No adult protection issues had been raised in relation to the home since the last inspection. What the service does well: There were no rigid rules or routines in the home and the people living there were able to spend their time as they chose. There were activities available for those wishing to take part and people were also encouraged to take part in tasks around the home. The expert by experience commented in her report: ‘Some more mobile residents had been given small tasks e.g. folding napkins, help laying tables, this gave them a feeling of independence and usefulness in their community it was greatly appreciated and was carried out under the guidance of staff.’ And Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 7 ‘The residents spoken to were contented with the in house socialising and did not feel the need to go out into the community seeking it. Although they were certain that if required there would be staff to accompany them.’ Visitors were made very welcome at the home and there were no set visiting times. The expert by experience commented after speaking to the people living in the home ‘Visitors were welcome at any time and could be entertained in either lounges or the privacy of their bedrooms if preferred.’ The menus at the home were varied and nutritious with choices available. The expert by experience joined the people living in the home for lunch and commented: ‘A choice of main meal was on offer at lunchtime. Staff were on hand to help those who found difficulty in feeding themselves but also discreetly withdrew when the resident wanted to try herself. Mealtime was a happy social occasion for residents with an easily digested menu well cooked served hot and tasty. All residents cleared their plates of food.’ The home was very comfortable and well maintained. The expert by experience commented: ‘This is a very welcoming home in appearance, bright, warm and clean with no offensive odours noted in any areas.’ The home had a core group of staff who had worked there for a considerable amount of time which was very good for the continuity of care of the people living in the home. The expert by experience commented about the staff team: ‘The staff were happy and cheerful being friendly but also respectful towards residents and appeared well versed in their individual needs.’ What has improved since the last inspection? The practice of recording information in communal books about the people living in the home had stopped ensuring their confidentiality. The medicines were being kept more securely as the medication room was not being used for any other purposes. The ‘residents committee’ had been reformed and it was here that activities were discussed and future projects and trips were planned. This ensured the people living in the home were asked about their preferences and choices. The recruitment procedures had improved ensuring the people living in the home were fully safeguarded. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 8 Staff were undertaking training refresher courses in safe working practices to ensure they had all the necessary skills and knowledge to care for the people living in the home. There had been several improvements made in the environment including new security gates, a lot of redecoration, a lot of new good quality furniture had been purchased and a new emergency call system had been installed. This provided the people living in the home with a safe comfortable home in which to live. 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. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 9 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 Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 10 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): 1, 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was adequate information available for people wanting to move into the home to help them decide if the home could meet their needs. The pre admission assessment procedures did not ensure that the needs of all the people being admitted to the home were known by the staff. People were being issued with a contract/statement of terms and conditions of residence at the point of admission to the home. EVIDENCE: The statement of purpose and service user guide for the home had been combined into one document. It had been updated since the new proprietors had taken over the home but was in the process of being updated again. The document did include the majority of the information required by anyone wanting to move into the home to enable them to decide if the home could meet their needs. It was recommended that the range of fees charged for living in the home was also included to help with this decision. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 11 The files for two people who had moved into the home were sampled. One of these included evidence that the acting manager had undertaken an assessment of the individual’s needs prior to admission that included all the necessary areas. The other file had no evidence that the staff at the home had carried out an assessment. The acting manager stated this would have been done. There was evidence that a social worker had been involved in this admission as there was a copy of the initial care plan drawn up them but there was no copy of the social worker’s assessment. Both files included copies of contracts/terms and conditions of residence at the home. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements were needed in the care planning and risk assessment processes to ensure they were individualised and staff knew how to meet the needs of the people living in the home and minimise any risks. The management of medicines needed to improve to ensure the people living in the home received their medication as prescribed. The staff respected the privacy and dignity of the people living in the home. EVIDENCE: Three files were sampled. Two were for people recently admitted to the home and one for a person who had lived in the home for a considerable amount of time. At the time of the inspection the care planning process was being changed and the care plans and risk assessments in place varied considerably in detail. The files sampled all included care plans. Those for the two people recently admitted were generic care plans that had only had the names changed in Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 13 most instances. Although some of the details for the staff to follow were good, for example, in relation to short term memory the care plans detailed how staff were to familiarise the individuals’ with their surroundings, the names and roles of staff and so on. It is very unlikely that both of the individuals could have their needs met in exactly the same way. It is important that the care plans for the people living in the home are individualised to ensure they receive person centred care. The care plans did not include any details of the social needs of the individuals or what their abilities were in relation to their personal care. One of the individuals had an extensive assessment that consisted of tick boxes for numerous areas of her life including, daily routines, activities, dietary preferences, vulnerability and communication. It was not clear from this what aspects had been identified as a need and the outcome of the assessment was not reflected in the care plans. The care plan for the person who had been in the home for some time was a little more comprehensive. Two of the three files included manual handling risk assessments. One of these was for a person who had a lot of handling needs and the assessment was very detailed. It included details of all the moves to be undertaken by staff and what the person was able to do for herself. The acting manager needed to ensure that all the people living in the home had manual handling risk assessments. Two of the three files also included tissue viability and nutritional screenings. Again the acting manager needed to ensure these were undertaken for all the people living in the home. It was not clear on one of the tissue viability assessments if the person was at risk or not as there was no indication as to what the score meant. Clearly from the daily records, weekly key worker diaries and the assessments that had been undertaken there were some challenging behaviours in the home. For example, one file stated in the summary of needs ‘verbally aggressive’ for another individual the daily records evidenced the person had been ‘shouting out’ and ‘banging doors’. There were no management plans in place for staff to follow in relation to any of these behaviours. All the people living in the home needed to have general risk assessments in place that included how any risks were to be managed or any behaviours managed. There was evidence that the people living in the home had access to medical professionals as required, for example, doctors, district nurses and attending hospital appointments. At the time of the last inspection the GP records were being recorded in a communal book and it was advised that these were recorded on a separate sheet for each person in order to comply with confidentiality and data protection. A separate sheet was included in all the files sampled however these were not always being completed and sometimes information about GP visits, changes to medication and so on were on daily records making it difficult to track the health care needs of the individuals. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 14 Staff needed to be more vigilant when recording this information and ensure it was done in the appropriate place. The medication system had been changed since the last inspection. Medication was now administered via a 28 day monitored dosage system. Only senior staff were administering medication and all had had some training. The acting manager had his own system in place for verifying the competence of staff in relation to administering medication also. There was no one self administering their medication at the time of this inspection. Some controlled medication was being administered and the records for these were appropriately completed with two staff signing to witness they had been administered. The balances held in the home at the time of the inspection were correct. A random audit was undertaken on the other medication in the home. The blister packs checked were correct however there were some discrepancies found in the boxed medications in the home and some could not be audited. These issues appeared to be arising because the balances of medication held in the home at the end of the 28 day cycle were not being carried forward to the next (medication administration record) MAR. It was also noted that one lot of medication had not been entered on the MAR chart at all as it had not been received from the pharmacist but from a clinic. The acting manager was advised that all medication received into the home must be recorded and there must be a complete audit trail for all medication. The privacy and dignity of the people living in the home was respected by the staff as evidenced by knocking on bedroom doors and the manner in which staff interacted with them. The expert by experience commented: ‘Staff were on hand to help those who found difficulty in feeding themselves but also discreetly withdrew when the resident wanted to try herself’ and ‘Bedrooms were well furnished, warm clean and bright and personalised by residents, who said they had freedom to use them whenever they wished, as some residents preferred to use their bedrooms the majority of the time.’ The bedrooms had a lockable facility and the proprietors were in the process of fitting suited locks to the bedroom doors. All those on the ground floor had been completed enhancing the choice for the people living in the home to lock their bedrooms and allow for access to the bedrooms in the event of an emergency. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home were afforded a lifestyle that met their needs, maintained contact with family and friends and provided choices and nutritious food at mealtimes. EVIDENCE: There were no rigid rules or routines in the home and the people living there were able to spend their time as they chose. There were activities available for those wishing to take part and people were also encouraged to take part in tasks around the home. The expert by experience commented in her report: ‘Some more mobile residents had been given small tasks e.g. folding napkins, help laying tables, this gave them a feeling of independence and usefulness in their community it was greatly appreciated and was carried out under the guidance of staff.’ Documented activities included, dominoes, cracker making, knitting, coffee mornings, card games, reading newspapers, exercise, going out to the local shops and watching DVDs. Staff also recorded comments about how the people Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 16 living in the home responded to the activities. The acting manager stated that the ‘residents committee’ had been reformed and it was here that activities were discussed and future projects and trips were planned, for example, individuals being involved in planting baskets for around the home and a trip to the sea life centre. The expert by experience commented: ‘The home organises outing during the year for those who wish to attend and provides in house activities at other times. There is no dedicated activities worker and staff on a rota basis undertake the various scheduled activities on a daily basis. However, there were no activities taking place on the day of visiting, with TV on in one lounge and sing-along music in the other. This was due to a pre organised staff training day.’ ‘The residents spoken to were contented with the in house socialising and did not feel the need to go out into the community seeking it. Although they were certain that if required there would be staff to accompany them.’ The home also organised events that relatives were invited to including barbecues and parties and these were well attended. Visitors were made very welcome at the home and there were no set visiting times. The expert by experience commented after speaking to the people living in the home ‘Visitors were welcome at any time and could be entertained in either lounges or the privacy of their bedrooms if preferred.’ The menus at the home were varied and nutritious with choices available. The records of food being served to the people living in the home needed to be further developed to ensure they included all the foods served and any special diets catered for. Comments received from the people living in the home about the meals included: ‘They are pretty good.’ ‘The meals are not very warm as the plates are cold.’ The expert by experience joined the people living in the home for lunch and commented: ‘A choice of main meal was on offer at lunchtime with a sandwich, crusts removed, for a resident who did not want a cooked meal. Staff were on hand to help those who found difficulty in feeding themselves but also discreetly withdrew when the resident wanted to try herself. Drinks were served with the meal and staff encouraged residents to take liquid with their meals. Mealtime was a happy social occasion for residents with an easily digested menu well cooked served hot and tasty. All residents cleared their plates of food.’ Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home were listened to and their views acted on. The training staff had received and the policies and procedures in the home ensured the people living there were safeguarded from abuse. EVIDENCE: The home had an appropriate complaints procedure in place. No formal complaints had been logged at the home. It was recommended that staff record any minor ‘grumbles’ made by the people living in the home and how these were resolved as further evidence that they listen to the people living in the home. Some anonymous concerns had been raised with the Commission about the attitude of some of the staff. This was discussed with the acting manager at the time of the inspection. No evidence was found during the course of the inspection to support the concerns. Generally the surveys returned to the Commission prior to the inspection indicated that people knew how to raise any complaints. Comments received included ‘the manager of course’ and ‘I would speak to the manager if I could contact him but it is difficult to get a word with him often.’ In relation to the last comment the acting manager felt he was always available for the people living in the home. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 18 The policies and procedures in relation to adult protection and whistle blowing were being updated at the time of the inspection. There was a copy of the multi agency guidelines for adult protection on site as well as a very comprehensive step by step guide for staff to follow in the event or suspicion of abuse. Staff were about to have their training in adult protection issues updated. The first session was due the day of the inspection but was rearranged due to the inspection. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical environment of the home had been improved and enabled the needs of the people living in the home to be met in a very comfortable and homely environment. EVIDENCE: The home had had new owners since the last inspection and several improvements had been made to what was already a very comfortable environment. The home was well maintained, furnished and decorated to a high standard. To improve the security of the home gates had been fitted to the side that could be locked at night. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 20 Communal space comprised of two lounges, a library and a dining room. The new proprietors had removed the wall in the dining room and made it into one large room which improved accessibility for the people living in the home. All the communal areas had been refurbished. New flooring and furniture had been purchased for all areas. Furniture included footstools and small side tables so that people were able to put their drinks down. The dining room furniture had been changed so that only four people were seated at each table to encourage interaction between them. The expert by experience commented: ‘The dining room is well equipped, bright and easy to manoeuvre about using walking aids. Tables are set for four persons, each resident has their chosen place.’ There were adequate numbers of toilets and bathing facilities throughout the home. The large assisted bathroom on the ground floor had had a Jacuzzi bath installed. The bath had been removed from the room opposite the dining room. This now housed only a toilet and wash hand basin and this had improved accessibility for the people living in the home and there was ample room for staff to assist where necessary. It was planned to have a walk in shower fitted in this room. There was a further bathroom on the first floor and the majority of the bedrooms had en-suite facilities. Bedrooms seen during the course of the inspection were well decorated and nicely furnished. Some had been completely refurbished. Locks had been fitted to bedroom doors on the ground floor. Those on the first floor were planned to be done also. The proprietors were advised to look into the people having access to bedside lighting. They had purchased some bedside lights but these were found to be too big and another variety was being explored. Bedrooms were personalised to the occupants’ choosing. The expert by experience commented: ‘Bedrooms were well furnished, warm clean and bright and personalised by residents, who said they had freedom to use them whenever they wished.’ The home had a variety of aids and adaptations including shaft lift, stair lift to two bedrooms, assisted bathing and toilet facilities and hand and grab rails. A new emergency call system had been installed throughout the home. The laundry was appropriately equipped with a sluice washing machine and a new commode pot disinfector had been installed just outside the back door of the home. The home was odour free and clean. The expert by experience commented: ‘This is a very welcoming home in appearance, bright, warm and clean with no offensive odours noted in any areas.’ Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 21 One of the people living in the home commented ‘we have a very good laundry service.’ It was noted that some COSHH items had been left in the bathrooms of the home these must be stored securely when not in use. Also there were some personal toiletries left in the bathroom which should have been returned to the individuals’ bedrooms after use and hard soap was in use in many of the communal facilities which did not promote good infection control. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and competencies were such that the needs of the people living in the home could be safely met. The recruitment procedures had improved and ensured the people living in the home were safeguarded. EVIDENCE: The home had a core group of staff who had worked there for a considerable amount of time which was very good for the continuity of care of the people living in the home. Staff turnover was relatively low and staffing levels were appropriate for the needs of the people living in the home at the time of the inspection. The acting manager confirmed the minimum staffing levels were four staff throughout the waking day one of whom was a senior and at times there were as many as six staff on duty. Catering, domestic and maintenance staff were also employed and the manager’s hours were supernumery to the care rota. The expert by experience commented about the staff team: ‘The staff were happy and cheerful being friendly but also respectful towards residents and appeared well versed in their individual needs.’ Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 23 A relative commented: ‘provide a warm friendly atmosphere open to all visitors.’ Only one member of staff had been recruited and stayed at the home since the last inspection. The file for this individual showed that the recruitment procedures had improved since the last inspection. All the required checks had been undertaken prior to the person starting work at the home including, two written references, POVA first check and medical questionnaire. The new staff member had undertaken a thorough induction in line with the specifications laid down by skills for care. It was difficult to assess the training undertaken by the staff team, as the home did not have a training matrix. The inspector was shown the training programme for the home which indicated all staff were to undertake updated training in moving and handling, adult protection, health and safety, infection control and basic first aid. Two sessions had been booked for each topic and staff were expected to attend one of the sessions. It was strongly recommended that the acting manager had a training matrix for the staff team detailing when and what training had been undertaken so that it was easy to identify any shortfalls. Information received on the AQAA indicated that over 50 of staff were qualified to NVQ level 2 or above. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager ensured the smooth running of the home in a competent manner. The health and safety of the people living in the home were generally well managed. The home needed to have a formal quality monitoring system in place based on seeking the views of the people living in the home with a view to continuous improvement. EVIDENCE: New providers had taken over the home since the last inspection. The former deputy manager was now the acting manager at the home. The providers and the acting manager were present throughout the inspection. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 25 The acting manager had worked at the home for a considerable amount of time and had all the relevant qualifications. He had several years experience of caring for older people and was well versed in the running of a residential home. This is the first home owned by the new providers and they showed full commitment in ‘getting it right’. The Commission had not received an application for the registration of the manager. The providers were advised this should be forwarded as soon as possible. The providers had purchased a quality assurance system but this was not fully operational at the time of the inspection. However there were systems in place to monitor the quality of the service offered at the home including a residents committee, key worker system, occasional satisfaction surveys and staff meetings. The new providers attended the home on a regular basis but were not completing their monthly reports as required by Regulation 26 of the Care Homes Regulations. The importance of this was discussed with them to ensure that someone was overseeing the conduct of the care home. Some monies were being managed for the people living in the home. The records for these were sampled and were generally satisfactory. Some minor issues were raised, for example, one receipt for hairdressing was missing and staff had forgotten to record the most recent transaction for one of the people living in the home. The health and safety of the people living in the home and the staff were generally well managed. Staff were receiving training in safe working practices. There was evidence on site of the servicing of the equipment in the home. It was recommended that the providers explore if the water system in the home needed to be checked for the prevention of legionella. The in house checks on the fire system were up to date, regular fire drills were being undertaken and staff had received fire training. All the requirements made by the fire officer at the most recent visit had been met. The fire officer had been back to the home to check for compliance and was satisfied with what had been done. The environmental health officer had also visited the home and only minor issues had been raised all of which had been addressed. The Commission had not received any Regulation 37 notifications from the home for a considerable amount of time. The acting manager was reminded that any event in the home that affects the well being of the people living there must be notified to the Commission so that are assured that accidents and incidents are managed appropriately. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 26 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 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14(1)(a) (b) Requirement There must be evidence on site that the needs of the people being admitted to the home are assessed prior to admission. Where applicable a copy of the social workers assessment must be obtained. This will ensure the staff at the home have all the necessary information prior to any one moving into the home. The registered person must ensure that the written care plans: - Detail the individual needs of the people living in the home. - Include sufficient detail to enable the care staff to know what actions are to be taken to ensure the individuals’ needs are met. (Previous time scale of 01/10/06 not met.) This will ensure the people living in the home receive person Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 28 Timescale for action 31/01/08 2. OP7 15(1) 14/02/08 3. OP7 13(5) centred care. There must be manual handling risk assessments in place for all the people living in the home. This will ensure the people living in the home are moved safely. There must be general risk assessments in place for the people living in the home. Where any challenging behaviours are identified there must be management plans in place for staff to follow. This will ensure that the people living in the home are not exposed to any unnecessary risks. There must be tissue viability and nutritional screenings undertaken for the people living in the home. These must indicate when people are at risk. There must be management plans for any identified risks. This will ensure the people living in the home are not exposed to any unnecessary risks. All medicines received in the home must be recorded on the MAR charts. Any balances of medication held in the home at the end of the 28 day cycle must be carried forward to the next MAR chart. There must be a complete audit trail for all medication held in the home. This will ensure the people living 31/01/08 4. OP7 13(4)(c) 31/01/08 5. OP8 12(1)(a) 31/01/08 6. OP9 13(2) 14/01/08 Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 29 7. OP26 13(3) in the home receive their medication safely. All COSHH substances must be kept securely when not in use. Personal toiletries must be returned to the bedrooms of the people living in the home after use in communal areas. Hard soap must be removed from communal bathing and toilet facilities. This will ensure the people living in the home are safeguarded. The registered person must ensure the Commission is notified of any events that affect the well being of the people living in the home as detailed in Regulation 37 of the Care Homes Regulations. This will assure the Commission that any incidents in the home are being managed appropriately and in the best interests of the people living in the home. 14/01/08 8. OP38 37 14/01/08 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 OP1 Good Practice Recommendations It is recommended that the service users guide includes information in relation to the fees charged at the home. This will ensure people wanting to live in the home have all the necessary information to make an informed decision about moving into the home. Staff should be more vigilant when recording health care appointments and their outcomes to ensure they are DS0000065660.V355977.R01.S.doc Version 5.2 Page 30 2. OP8 Hollywood Rest Home 3. OP15 4. OP16 5. 6. OP24 OP30 7. OP31 8. OP33 9. 10. OP33 OP38 recorded on the correct sheet so that they can be easily tracked. The records of food being served to the people living in the home needed to be improved to ensure they detailed all the meals served and whether any special diets were being catered for. It was recommended that staff record any minor ‘grumbles’ made by the people living in the home and how these were resolved as further evidence that they listen to the people living in the home. Bedside lighting should be available to the people living in the home. This will ensure they have adequate lighting should they wish to get out of bed at night. It was strongly recommended that the acting manager had a training matrix for the staff team detailing when and what training had been undertaken so that it was easy to identify any shortfalls. An application for the registration of the acting manager should be forwarded to the Commission as soon as possible. This will ensure someone is accountable for the running of the home on a day to day basis. The registered individual should ensure that there are records on site of the monthly visits carried out at the home. This will ensure someone is overseeing the conduct of the care home. The home should have in place a formal quality monitoring system based on seeking the views of the people living in the home with a view to continuous improvement. It is recommended that the providers explore if the water system in the home needs to be checked for the prevention of legionella. This will ensure the people living in the home are not put at risk. Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Hollywood Rest Home DS0000065660.V355977.R01.S.doc Version 5.2 Page 32 - 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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