Inspection on 15/06/06 for Hollywood Rest Home

This inspection was carried out on 15th June 2006.

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 05/02/09

Hollywood Rest Home 03/12/07

Hollywood Rest Home 24/01/07

Hollywood Rest Home 17/11/05

Hollywood Rest Home 09/06/05

Hollywood Rest Home 21/01/05

Hollywood Rest Home 28/06/04

Hollywood Rest Home 27/02/04

Hollywood Rest Home 14/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Hollywood Rest Home 34 Cresthill Avenue Grays Essex RM17 5UJ Lead Inspector Michelle Love Key Inspection 15th June 2006 10:30 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 DS0000018090.V299500.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 DS0000018090.V299500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollywood Rest Home Address 34 Cresthill Avenue Grays Essex RM17 5UJ 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) 01375 382200 01375 381611 hrh@hollywoodresthome.co.uk Mr Rajpaul Singh Dhillon Mr Gurmit Singh Dhillon Mr Rajpaul Singh Dhillon Care Home 19 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (19) of places Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: Hollywood Rest Home is situated in a quiet residential area on the outskirts of Grays. It currently offers 17 places on two floors with a passenger lift to the first floor. The home offers single and double bedrooms, a limited number of which have en-suite facilities. There are on-going building works to improve the premises and increase the numbers to 25 places, and works remain in progress. The home currently offers residents one large lounge/dining area and one smaller lounge area. The home has a rear garden which is well maintained and accessible to residents. Limited parking is available to the front of the property. The weekly fees range from £376.75 to £485.00. Additional charges/costs are incurred by residents relating to hairdressing, purchase of personal toiletries, newspapers/magazines, sweets etc, and the above information was detailed within the homes pre inspection questionnaire. Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This `key` site inspection was undertaken by Michelle Love and Bernadette Little, over a period of approximately 8 hours. During this visit a number of records and documents were looked at i.e. individual resident’s care plans and associated documentation, staff rosters, the homes Statement of Purpose and Service Users Guide, staff recruitment files etc. In addition to the above a tour of the premises was undertaken, discussion took place with the registered providers, registered manager, deputy manager, care staff on duty, visiting relatives and several residents. A number of questionnaires were forwarded to resident’s representatives and visiting professionals to seek their views as to whether or not they feel that the home is providing appropriate care. Comments were positive and stated that “staff are always welcoming and pleasant”, “staff are very friendly and helpful and are doing all they can” and “staff will always make time to discuss my client. They provide good care and have an understanding of my clients needs”. What the service does well: What has improved since the last inspection? Continued progress is being made to improve the home’s environment and to complete building works/décor. The new main lounge is in full use and resident’s comments relating to this newly created space were positive. Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 6 Some training has been provided to staff relating to both mandatory and specialist courses. An application to vary the homes registration has recently been agreed. The homes registration has increased from 17 to 19 residents, of which 10 older people who have a formal diagnosis of dementia can be admitted. 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. Hollywood Rest Home DS0000018090.V299500.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 Hollywood Rest Home DS0000018090.V299500.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): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and Service Users Guide, however some aspects are not reflective of what actually happens in practice. Not all residents who are admitted to the care home are assessed prior to admission. Individual contracts setting out the homes terms and conditions were not evident for all residents. EVIDENCE: Since the last inspection to Hollywood Rest Home, both the Statement of Purpose and Service Users Guide have been reviewed (18.4.06). On the day of the site visit a copy of both documents was requested. On inspection of the Statement of Purpose and Service Users Guide it was evident that some elements were inaccurate and somewhat misleading i.e. the Statement of Purpose states that the registered provider/manager works alongside carers and personally deals with the needs of residents. This is inaccurate and does not accurately reflect that the provider/manager does not assist care staff in providing specific care to residents. Additionally the document states: “the Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 9 home is to increase its registration from 17 to 27 beds”. The registered provider is reminded that any change to the homes registration is not merely a formality and that the Commission will need assurances and evidence that the provider can meet the regulatory requirements. The Commission will write separately to the registered provider/manager in relation to reviewing both the Statement of Purpose and Service Users Guide. The home has a system in place for assessing prospective residents. This is confirmed within the homes Service Users Guide. However it was evident that no pre admission assessment was undertaken for the newest resident to be admitted to the care home by the registered provider/manager. A further three individual residents files were inspected and all were noted to have a pre admission assessment in place which had been completed by the deputy manager. No evidence was available to indicate that the prospective resident and/or their representative had visited the care home prior to admission or received a copy of the homes Statement of Purpose/Service Users Guide. The registered provider/manager was requested to provide three residents contracts. Only one contract was available on the day and the registered provider/manager stated: “we are still waiting for those”. Nonetheless there were no contracts of residency either between Hollywood Rest Home and the resident. The registered person must ensure that all residents residing at the care home are issued with a contract setting out the homes terms and conditions. Hollywood Rest Home DS0000018090.V299500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a system for recording residents individual care needs. The medication processes within the home were observed to be satisfactory. Information relating to funeral arrangements/terminal care were not always recorded. EVIDENCE: At this site visit four individual resident’s care plans and associated documentation were inspected. It was concerning to note that no care plan/risk assessments had been devised for the newest resident to be admitted to the care home by the registered provider/manager. The Commission recognises that the resident was placed as an emergency admission, however a care plan/risk assessments should have been written. As a result of the Commissions concerns an `Immediate Requirement` notice was issued. Other care plans inspected, evidenced that these had been written by the deputy manager. Information recorded was noted to be informative and relatively detailed in most cases. Additional information is required outlining individual resident’s specific care needs and how care is to be delivered by care Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 11 staff i.e. one care plan detailed that the resident could be difficult at times. Precise and unambiguous information must be detailed identifying how the resident can be difficult, are there any known triggers and how staff are to deal with the resident’s behaviours in a consistent way. Formal assessments relating to falls, manual handling, pressure sores and nutrition were readily available. Risk assessments were completed for three out of four care plans/documentation inspected, and in most cases were comprehensive identifying possible risk areas for individual residents. Again specific information is required outlining the exact area of risk and how this is to be managed by care staff i.e. one persons records indicated that they had poor communication. The risk assessment did not identify why this was a risk or how staff were to communicate with the resident e.g. look for non verbal lines of communication etc. It was very concerning to note that one person’s risk assessment stated that they should not have access to razors or sharp objects and to be supervised at meal times. On the day of the site visit the resident was observed to be left unsupervised at lunchtime and had the use of sharp objects in which to eat their meal with. This is unsatisfactory and dangerous; the registered provider/manager must ensure that sufficient numbers of staff are available to provide `hands on` assistance to individual residents where required. None of the care plans inspected depicted a photograph of the resident. As highlighted at the last inspection, daily care records were once again not being written on some days. Additionally some entries did not record staff’s interventions i.e. one person’s records indicated that they complained about an aching back/back pain. No information was recorded depicting what action was taken by staff to address the issue i.e. consider giving pain relief/see a GP. Records for another resident indicated that on occasions they refused their lunchtime meal. This was not highlighted on the care plan or highlighted as a possible risk. None of the care plans inspected had information relating to funeral/terminal care arrangements. It was positive to note that the homes medication storage, administration and record keeping were observed to be satisfactory and no issues were highlighted at this site visit. Hollywood Rest Home DS0000018090.V299500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Since the beginning of June 06 no programme of activities has been provided to residents. There is little evidence to indicate that residents are offered choice and that residents are empowered to make decisions. Meals for residents are plentiful and the standard of hygiene within the kitchen remains satisfactory. EVIDENCE: Since the last inspection the homes category of registration has been altered. The care home has increased the number of places available from 17 to 19 and can now admit no more than 10 older people who have a formal diagnosis of dementia. As a condition of the homes new registration being granted the registered provider had to provide in addition to three staff being on duty during the day, a person employed for four hours per day Monday to Friday for activities. The rosters evidence that an activities person was employed from the first week in April 06 to the second week in June 06, however they have since left the employment of the home and no additional member of staff has been deployed to cover this role. This is unacceptable and until a suitable person is recruited the registered provider/manager must ensure that an additional member of staff is deployed to solely instigate an activity programme for residents as previously agreed. Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 13 A folder evidencing activities undertaken by residents was readily available and this included such activities as 1-1 sessions, listening to music, manicures, playing dominoes, playing cards, drawing and sing-a-longs. Unfortunately records tended to confirm that only a small group of residents participated and no activities have been undertaken for those people who have complex/dementia needs and requirements i.e. lack of motivation, poor communication skills, poor concentration/short term memory/confusion, sensory needs etc. Observation of the lunchtime meal for residents was undertaken by inspectors. The main dining room provided 3x tables of 3x residents and 2x residents were observed to sit in the small lounge to have their meal. Those residents who require assistance from staff to be fed were noted to remain in their lounge chairs. It was positive to note that the dining tables were pleasantly set out with tablecloths and condiments readily available. On the day of the site visit the weather was very hot and humid, consideration must be given by the cook as to the appropriateness of the menu i.e. residents were offered a choice of either meatballs/pasta or faggots/mash/vegetables/gravy and rice pudding/yoghurts for diabetics as desert. All residents were offered orange juice however there appeared to be no other choice of drink available. The inspectors noted that three residents require 1-1 assistance with feeding and that two residents require significant verbal/physical prompting to eat their meal. As stated previously it was concerning to note that one resident was not supervised in line with their care plan and that the registered provider/manager did not provide any support/assistance to care staff and residents during the lunchtime period. The deputy manager and another staff member were observed to provide sensitive and appropriate support to individual residents, however three residents had to wait sometime before receiving their meal. The registered provider/manager is reminded that he is included on the roster as one of the three care staff officially on duty. The kitchen facilities remain clean and well organised and much effort has been made by the cook to maintain this standard. Hollywood Rest Home DS0000018090.V299500.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not received any complaints since the last inspection. The home has a Protection of Vulnerable Adults Policy and Procedure in place. It is unclear as to how many staff had actually attained training relating to abuse. EVIDENCE: Neither Hollywood Rest Home or the Commission for Social Care Inspection had received any complaints since the last inspection. The complaints procedure is displayed in the hallway on a notice board, which is located close to the dining room. The home has a copy of Thurrock County Councils Protection of Vulnerable Adults (POVA) Policy and Procedure. It was unclear as to how many members of staff have actually attained POVA training. The deputy manager and one member of care staff demonstrated a good understanding and awareness of POVA procedures. The registered provider/manager must submit evidence of staff’s training relating to POVA within 7 days of receiving this report. Hollywood Rest Home DS0000018090.V299500.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was generally observed to be clean, tidy and odour free and there were no major health and safety issues highlighted. EVIDENCE: Since the last inspection works have been completed to five bedrooms within the main house and these are now occupied. Works are relatively near completion pertaining to the additional bedrooms i.e. rooms need a good clean, en-suite facilities to be fully plumbed in and operational and fixtures and fittings fitted. Once completed the Commission for Social Care Inspection will inspect the premises and the process for registration can be initiated. The main lounge area is complete and being occupied by residents. On the day of the site visit one double electrical socket was placed out of action and sealed as it was broken and could have caused a health and safety risks to both residents and staff. The only other minor health and safety issue related to a Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 16 torn stair carpet (one tread) as it could cause a tripping hazard. One resident’s bedroom carpet was observed to be stained and another resident was noted to have a torn headboard. A couple of bedrooms were noted to have an unpleasant odour. The odour was observed at 4.45 p.m. One resident’s bedroom door was noted to not fully self close. All bedrooms inspected were observed to be personalised and individualised. Residents spoken with stated that they were happy with their bedroom. Hollywood Rest Home DS0000018090.V299500.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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels and staff deployment are not always appropriate to meet the needs of current residents. The home’s recruitment practices are not robust and do not protect residents. Some staff training has been undertaken since the last inspection. EVIDENCE: On inspection of 4 weeks staff rosters for the period 22.5.06 to 15.6.06 inclusive it was evident that agreed staffing levels are not being maintained i.e. on the day of the site visit the registered provider/manager arrived at the care home at the same time as inspectors (10.35 a.m.), yet the staff roster detailed that he was due to commence the shift at 10.00 a.m. This only left two members of staff on duty between 10.00 a.m. and 10.35 a.m. Additionally the staff roster details that only 2x staff were on duty between 07.00 a.m. and 09.00 a.m. when the deputy manager commenced their shift. When questioned the registered provider/manager advised that another staff member was available (SK), however when questioned both the staff member and the deputy manager confirmed that they were employed solely as a laundry person and not as a carer and that this decision had been made by the registered provider/manager. The staff rosters evidenced that the above occurrence as described is happening on a regular basis. It was unclear as to whether or not the registered provider/manager arrives at the care home later than detailed on the roster on a regular instance. All staff when questioned were hesitant and refused to answer the question. As stated previously it also Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 18 remains of concern that the registered provider/manager appears to be detached from the actual care provision processes within the home, yet he is part of the actual care roster and is calculated as part of the care staffing requirements. The registered providers/manager were advised that following this site visit additional unannounced random inspections would be conducted to the care home. As a result of the concerns, until further notice a copy of the homes staffing roster must be forwarded to the Commission on a weekly basis. Additionally and as a result of the Commissions concerns an `Immediate Requirement` notice was issued. The registered provider/manager does not appear to have any supernumerary hours. On inspection of three staff recruitment files it was disappointing and concerning that the need for robust recruitment procedures to protect residents continue to be breached and ignored by the registered provider/manager. Gaps were observed relating to only one written reference for one employee, no photograph for one person, no start dates for all three employees, no declaration advising that staff are mentally and physically fit to work, employment histories not fully explored, no proof of identification for one person, no POVA 1st/CRB for one person and no induction/training for the three employees. In addition there were no job descriptions evident and no evidence whether or not one person required a work permit. Following discussions with the registered provider/manager, he confirmed to the inspector that he had failed to secure records relating to CRB/POVA 1st for one employee, that none had received an induction and that none of them had received any training since commencement of their employment. This is unacceptable and it is essential that the homes recruitment procedures improve in line with regulatory requirements as detailed within the National Minimum Standards and Care Homes Regulations for Older People as continued non-compliance will result in an enforcement notice being issued. Training records were inspected for two members of staff and for the registered provider/manager. One person’s file evidenced that they had received Food Hygiene and Managing Aggression training since the last inspection. No confirmation was available to indicate that they had received training relating to Fire Awareness, Health and Safety, Basic First Aid, Manual Handling, Infection Control and specific courses relating to the specialist needs/conditions associated with old age. The other member of staff was noted to have received Manual Handling, Managing Aggression and Infection Control since the previous inspection. The registered provider/manager file indicated that he has received training relating to Manual Handling, Managing Aggression and Epilepsy Awareness and Administration of Rectal Diazepam. It was positive to note that 12 members of staff are to receive appointed first aid training on the 5th July 2006. The registered manager/provider must forward an up to date training matrix evidencing all training courses attended by staff and dates attained within 7 days of receiving this report. Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 19 Currently 5x members of staff have attained NVQ Level 2, 1x member of staff is undertaking NVQ Level 2, 1x staff member is undertaking NVQ Level 3 and the deputy manager is taking NVQ Level 4. No records of induction were available for the newest staff employed at the care home. As a result of the Commissions concerns an `Immediate Requirement` notice was issued relating to staff induction and training. Hollywood Rest Home DS0000018090.V299500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although residents within the home appear to have a good relationship with the registered provider/manager, some aspects of his management are poor and this has resulted in an increase in Statutory Requirements/Recommendations highlighted. Formal staff supervision is conducted at the home, however it is not up to date. The health, safety and welfare of residents and staff are not always promoted and protected. The home has devised and implemented a quality assurance system to seek residents and their representatives’ views. EVIDENCE: The registered provider/manager advised the inspector that he is no longer undertaking the Registered Manager’s Award/NVQ Level 4. Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 21 The last inspection to the care home evidenced that progress was being made by the registered providers/manager and his staff team to address previous identified shortfalls and to work in line with the National Minimum Standards and Care Homes Regulations for Older People. It is disappointing to note that at this site visit there was clear evidence to indicate that improvement has deteriorated, especially in those elements which are controlled and maintained by the registered provider/manager i.e. staff rosters/staffing levels, staff recruitment, staff training. Records indicate that the registered provider/manager has implemented a quality assurance system in the home, which aims to seek the residents and their representatives’ views. The surveys were complimentary regarding care staff and negative comments were in relation to a lack of activities to keep residents stimulated and occupied. Most surveys appeared to be completed by the same person. The registered provider/manager confirmed that residents meetings are not held. The home does not look after resident’s monies. The registered provider/manager advised that resident’s families are invoiced by the home. Those resident’s who are funded by local authorities have their monies paid into a separate account. On evidence of a random sample of staff supervision documents, records indicated that these are not being conducted regularly or in line with National Minimum Standards recommendations. The most recent dates detailed were for August/September 2004 and November 2005. No risk assessments were available for safe working practices. A limited number of COSHH (Control of Substances Hazardous to Health) data sheets were available (6). A current gas and electrical safety inspection certificate was available. Records relating to fire equipment, the homes fire alarm system, fire extinguishers, monthly fire alarm/emergency lighting tests were all deemed satisfactory. Monthly records were evident pertaining to fire drills, however they did not detail the names of those staff who participated. No passenger lift safety inspection certificate or records for portable appliance testing were available. The registered provider/manager must ensure that a safety inspection is undertaken for the homes passenger lift and a copy of the certificate is forwarded to the Commission within 14 days upon receipt of this report. It was evident that the Registered Provider had a limited understanding of the management/risks pertaining to legionella e.g. ensuring that cold water temperature checks are undertaken and that shower heads are checked and regularly cleaned. Hollywood Rest Home DS0000018090.V299500.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 2 2 1 2 1 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 2 X 2 Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 and 5 Requirement Timescale for action 01/09/06 2. OP2 3. OP3 4. OP3 The registered persons must revise the homes Statement of Purpose and Service Users Guide to ensure that information documented is accurate and reflects what is provided at the care home. 5(b)(c) The registered person must ensure that all residents are issued with a contract of residency/terms and conditions. 14 Ensure that all prospective residents are assessed prior to admission and that there is sufficient evidence to indicate that the home can meet the person’s needs. 17(1)(a) 2 The registered person must ensure that there is a photograph of each resident on their individual file. 01/09/06 28/07/06 01/08/06 5. OP7 15(1) 6. OP7 13(4)(c) 7. OP11 12(2) Previous timescale of 1.2.06 not met. Ensure that all resident’s residing 28/07/06 at the home have a written detailed and comprehensive plan of care. The registered person must 28/07/06 ensure that risks to residents are identified and risk assessments devised for all areas of assessed risk. The registered person must 01/09/06 DS0000018090.V299500.R01.S.doc Version 5.2 Page 25 Hollywood Rest Home 8. OP12 16(2)(m) and (n) ensure that residents can make decisions in respect of their health and welfare. This refers specifically to funeral/terminal care arrangements. Ensure that all residents receive an appropriate programme of activities which meet their individual needs. Previous timescale of 01.03.05 and 14.2.06 not met. The registered person must ensure that residents are given choices wherever possible and take into account their wishes and feelings. The registered person must ensure that residents who require assistance with feeding are appropriately assisted by those staff on duty. Ensure that all staff working within the home receiving training relating to POVA. The registered person must ensure that at all times competent persons are working at the care home in such numbers as are appropriate for the needs of residents. Previous timescale of 01.03.05 and 1.2.06 not met. The registered person must ensure that all records as required by regulation have been sought and are readily available. Previous timescale of 1.2.06 not met. The registered person must ensure that all members of staff receive training appropriate to the work they are to perform. This refers to both mandatory and specialist. DS0000018090.V299500.R01.S.doc 01/09/06 9. OP14 12(2) 28/07/06 10. OP15 12(1)(a) and (b) 28/07/06 11. 12. OP18 OP27 13(6) 18(1)(a) 01/10/06 28/07/06 13. OP29 17(2),Sch 4,19,2 14/08/06 14. OP30 18(1)(c) (i) 01/10/06 Hollywood Rest Home Version 5.2 Page 26 15. OP31 7 and 9 16. 17. OP36 OP38 18(2) 23(2)(c) Previous timescale of 1.5.06 not met. The registered person/manager must be `fit` to manage the care home in accordance with the NMS and Care Homes Regulations for Older People. Ensure that all staff receive regular supervision. Ensure that all equipment is maintained and serviced appropriately on a regular basis. This refers to the homes passenger lift. 28/07/06 28/07/06 07/08/06 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. 4. 5. 6. 7. Refer to Standard OP5 OP7 OP7 OP28 OP30 OP38 OP38 Good Practice Recommendations Ensure that trial visits are offered to prospective residents and/or their representatives and that there is written evidence available. More care/senior staff are empowered to write detailed and comprehensive care plans/risk assessments. Daily care records should be written after every shift as part of good practice procedures and contain evidence of care provided and activities undertaken by residents. 50 of care staff should attain NVQ Level 2 or equivalent. Ensure that all staff are suitably inducted and evidence of their induction is available. Ensure that COSHH data sheets are available for all items utilised within the care home, and that COSHH risk assessments are devised. Ensure that as part of good practice procedures, hot and cold water temperatures are monitored and recorded for wash hand basins and baths/showers. Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Hollywood Rest Home DS0000018090.V299500.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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