Inspection on 17/11/05 for Hollywood Rest Home

This inspection was carried out on 17th November 2005.

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 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

Hollywood Rest Home 05/02/09

Hollywood Rest Home 03/12/07

Hollywood Rest Home 24/01/07

Hollywood Rest Home 15/06/06

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 Unannounced Inspection 17th November 2005 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 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.V266855.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hollywood Rest Home Address 34 Cresthill Avenue Grays Essex RM17 5UJ Telephone number Fax number Email address 01375 382200 01375 381611 hrh@hollywoodresthome.co.uk Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Rajpaul Singh Dhillon Mr Gurmit Singh Dhillon Mr Rajpaul Singh Dhillon Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 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. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that took place over 5.5 hours by two inspectors. During the inspection a number of records and documents were looked at and there was a tour of the premises at different times during the day. In addition the deputy manager, care staff and some residents were spoken with. The registered manager was spoken with briefly, however he did not stay for the majority of the inspection, as he was feeling unwell. What the service does well: What has improved since the last inspection? What they could do better: Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 6 The registered person must ensure that other members of staff are empowered to support the deputy manager with records/care planning processes. The registered person must ensure that the number, of hours they work at the care home are reduced to an acceptable level. All appointed members of staff must undergo robust and stringent recruitment procedures. Appropriate training courses must be provided to all members of staff and this must include both specialist and mandatory courses. Training must be kept up to date and reviewed regularly. 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.V266855.R01.S.doc Version 5.0 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.V266855.R01.S.doc Version 5.0 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, 4 and 5 Arrangements continue to be made to ensure that residents are assessed prior to admission. It remains unclear as to whether or not prospective residents are given information and have the opportunity to visit the home prior to admission. EVIDENCE: Since the last inspection two new residents have been newly admitted to the care home. Pre Admission Assessments were completed for both residents and included information from their placing authorities. No photographs of either resident were evident within their personal file. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 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 and 11 Improvements highlighted at the previous inspection pertaining to the homes care planning processes have been maintained. Medication systems at the home are well managed and maintained. Little evidence continues to be detailed in relation to resident’s views. EVIDENCE: On inspection of two individual care plans and risk assessments these continue to contain detailed information depicting evidence of resident’s health, personal, emotional and social care needs. It is evident that the deputy manager has a very good understanding and knowledge of how to complete a detailed individual plan of care for residents. No other members of staff have received training relating to care planning/report writing. The majority of the care plans have been written by the deputy manager and there is little evidence to indicate that others are empowered to contribute to the care planning process. The Commission is concerned that should she decide to leave the care home/become absent for a period of time, there is a possibility that the care planning processes within the home will deteriorate. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 10 Improvement is required pertaining to daily care records e.g. no entries were available on some days and some lacked specific information relating to staff’s interventions/nature of resident’s aggression/behaviours. At the time of the inspection one tablet was found on the table within the home’s office. In addition keys for the medication cabinet were easily accessible and labelled for anyone to see. The deputy manager was advised at the time of the inspection of the inappropriateness of keeping keys on display. Other than one omission, medication administration records were seen to be satisfactory. Medication’s which are stored within bottles and packets, should be dated and signed once opened. No changes have been made to the home’s medication policies and procedures. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 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 and 15 Activities within the home and local community remain fairly limited for residents. Meals for residents are plentiful and the standard of hygiene within the kitchen is much improved. EVIDENCE: Unfortunately there is little evidence to indicate that residents receive meaningful opportunities for stimulation and occupation. Since the last inspection (9.6.05) the home’s record of social activities details that residents have received planned activities on seven occasions. Activities provided to residents have included a clothes party, the visiting hairdresser, the making of Christmas table labels/paper flowers and an external visitor from the Body Shop. The lunchtime meal for residents looked appealing and plentiful. Residents were observed to receive appropriate support and assistance from care staff. On inspection of the home’s kitchen, this was observed to be clean and organised. Food stored within kitchen cupboards and the home’s fridge/freezer were clearly labelled/wrapped. Soap and paper towels were also readily available. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 No changes have been made to the home’s complaint and adult protection policies and procedures since the last inspection. Staff have knowledge and an understanding of adult protection issues which protects residents from abuse. EVIDENCE: Since the last inspection the home has received no complaints or protection of vulnerable adults issues. Staff training records evidence that since 9.6.05 five members of staff have undertaken protection of vulnerable adults training. Evidence of training certificates, were not available for all members of care staff on the day of inspection. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Building works continue to be in progress at Hollywood Rest Home. The home was clean, tidy and odour free on the day of inspection and there were no health and safety issues highlighted. EVIDENCE: Since the last inspection a new lawn has been laid and the new main office completed. The sleep in room still requires furnishing and an intercom system fitted so that `sleep in` staff can be contacted by waking night staff. Five bedrooms within the main house remain incomplete and works are still outstanding i.e. all rooms need a good clean, en-suite facilities/communal bathrooms to be fully plumbed in and operational and curtains fitted. The registered provider was advised that the Commission would inspect these bedrooms once they were ready for occupation. A fence is to be fitted around the pond area as soon as possible and a gate fitted to the side entrance. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 14 It was positive to note that the main kitchen was much tidier, clean and better organised. Food items stored in cupboards/fridge/freezers were stored and labelled appropriately. Liquid soap and paper towels were readily available for kitchen/care staff. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 15 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 Resident’s needs are met by adequate numbers of staff at the care home. The procedures for the recruitment of staff are better but gaps still exist. Training still needs to be improved for the majority of care staff. EVIDENCE: Since the last inspection one new member of staff has been newly employed. Some records as required by regulation were readily available, however gaps were observed pertaining to no job description, no contract, no photograph evident and no start date recorded. No evidence was available to indicate that the new employee had undertaken COSHH (Control of Substances Hazardous to Health) or Health and Safety training. No record of induction was available for the newest member of staff. On inspection of several weeks staff rosters, these continue to indicate that the registered provider/manager is working in excess of up to 60 hours per week, seven days per week without an appropriate day off duty. It was observed that the cleaner was not detailed within any of the staff rosters. On inspection of staff training records, these evidenced that since the last inspection four members of staff have received Protection of Vulnerable Adults training. Evidence was also available detailing that some staff have received and read a copy of adult protection guidelines. Records indicate that some gaps still exist in relation to not all staff having up to date mandatory training i.e. manual handling, basic food hygiene, medication and basic first aid. A limited number of staff had received training relating to pressure care Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 16 management and continence management. The deputy manager advised that herself and another senior member of care staff undertook a four day training course on Valuing Older People/Current Care Practices for Older Adults in July 2005. This four day course covered diabetes, continence management, pressure area care/preventions etc. All staff have undertaken distance learning health and safety training and were due to complete late November 2005. Currently six members of staff are undertaking NVQ Level 2. No one is currently undertaking NVQ Level 3. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 17 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): 38 The health, safety and welfare of residents and staff are not always promoted and protected. EVIDENCE: Within the home’s main COSHH file, only two data sheets were evident for substances used within the home. No COSHH risk assessments or safe working practice assessments were evident. The home’s electrical safety certificate, passenger lift certificate, certificate for the home’s fire alarms and bath hoist were readily available but all out of date. In addition certificates for the 2x Oxford Mermaid hoists and 1x Molifit Electric hoist had expired. It was evident that hot water temperatures from baths/hand basins were not recorded or monitored. The registered person must ensure that all equipment and the home’s electrical systems are appropriately maintained. Evidence must be provided to the Commission within 21 days Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 18 detailing that all systems/equipment have been serviced and a copy of all outstanding certificates forwarded. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 19 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 2 2 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation Requirement Timescale for action 01/02/06 2 OP9 3 OP12 17(1)(a) 2 The registered person must ensure that there is a photograph of each resident on their individual file. 13(2) The registered person must ensure that suitable arrangements are made for the recording and safekeeping of medicines received into the home. 16(2)(m) Ensure that all residents receive and (n) an appropriate programme of activities which meet their individual needs. Previous timescale of 01.03.05 not met Ensure that all parts of the home are free from risks to residents. The registered person must ensure that at all times competent persons are working at the care home. Previous timescale of 01.03.05 not met The registered person must ensure that all records as required by regulation have been sought and are readily available. DS0000018090.V266855.R01.S.doc 21/01/06 14/02/06 4 5 OP19 OP27 13(4)(a) and (c) 18(1)(a) 14/02/06 01/02/06 6 OP29 17(2),Sch 4,19,2 01/02/06 Hollywood Rest Home Version 5.0 Page 21 7 8 OP27 OP30 17(2), Sch 4(7) 18(1)(c) (i) 23(2)(c) 9 OP38 Ensure that the duty roster details all members of staff working at the care home. The registered person must ensure that all members of staff receive training appropriate to the work they are to perform. Ensure that all equipment is maintained and serviced appropriately on a regular basis. 21/01/06 01/05/06 14/02/06 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 Refer to Standard OP7 OP7 OP30 OP38 Good Practice Recommendations More care/senior staff are empowered to write detailed and comprehensive care plans/risk assessments. Daily care records should be written daily and contain evidence of care provided and activities undertaken by residents. 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. Hollywood Rest Home DS0000018090.V266855.R01.S.doc Version 5.0 Page 22 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. 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