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Inspection on 03/12/07 for Hollywood Rest Home

Also see our care home review for Hollywood Rest Home for more information

This inspection was carried out on 3rd December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff at the home, are caring and welcoming and have a good knowledge and understanding of individual resident`s needs. Visitors to the home are made to feel welcome. Staff morale at the home is good. The management team ensure that prospective residents are assessed prior to admission so that they are able to meet the individual`s needs. Residents are actively encouraged and enabled to participate in a range of activities, which meet their social care needs. Positive comments were also made about the food at the home. Residents and/or their representatives can raise concerns about the service freely and any complaints received are listened to, taken seriously an acted upon in a timely manner.

What has improved since the last inspection?

Improvements were observed in relation to the home`s environment so as to enhance facilities for residents. A new dining room and large communal lounge has been created, the laundry area has been redeveloped and new equipment purchased and redecoration to other areas of the home. Comments from residents relating to their personal space were positive. The number of statutory requirements as highlighted at the previous inspection to the home has reduced. Although there are still some requirements, there is clear evidence to indicate that progress is being made to address shortfalls.

What the care home could do better:

Care planning at the home, needs to be further developed so that residents` care needs are clearly identified. This will provide care staff with up to date information so as to ensure proactive and safe delivery of care, which can meet their individual needs. Medication administration and other practices need to be developed to ensure that these are in line with current regulation and ensure/promote residents` safety and wellbeing at all times. Staff training needs to be provided for some staff in key and additional subjects, so that residents needs are met by appropriately trained staff. Inductions for new staff must be comprehensive and detailed to enable staff to support the people living at Hollywood Rest Home. Further training must be considered in the area of manual handling for staff, as current poor practices adopted by some members of staff are not in line with residents` care plans and potentially places them at risk.

CARE HOMES FOR OLDER PEOPLE Hollywood Rest Home 34 Cresthill Avenue Grays Essex RM17 5UJ Lead Inspector Michelle Love Unannounced Inspection 3rd December 2007 09:00 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.V353682.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.V353682.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 27 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (27) of places Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Hollywood Rest Home is situated in a quiet residential area on the outskirts of Grays. It is registered to provide care and accommodation for up to 27 older people who may have a formal diagnosis of dementia. Accommodation is provided on two floors with a passenger lift to the first floor. There is a choice of two large communal lounges and one dining room. Hollywood Rest Home has an attractive garden to the rear of the property, which is well maintained and accessible to residents. Limited parking is available to the front of the property. The weekly fees range from £395.00 to £421.60 Additional charges/costs are incurred by residents relating to hairdressing, purchase of personal toiletries, newspapers/magazines and sweets etc. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. The inspection was undertaken over a nine hour period with two inspectors. At this inspection all the key standards and the management team’s progress against their previous agenda for action were assessed. Prior to the site visit the management team of the home had submitted an Annual Quality Assurance Assessment, which provided additional information about what the management team do well, what has improved and what requires further development. This inspection was conducted with assistance from the registered provider/manager and members of the care staff team. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. A tour of the premises was undertaken during the inspection. During the visit, residents and members of staff were spoken with and their comments are used within the main text of the report. Prior to the inspection, relatives and healthcare professional surveys were forwarded to seek peoples’ views. It was disappointing that few surveys were returned to the Commission for Social Care Inspection, however comments received have been incorporated into the main text of the report. Feedback on the findings of the inspection were summarised at the end of the day and the opportunity for further discussion and/or clarification was given. What the service does well: Staff at the home, are caring and welcoming and have a good knowledge and understanding of individual resident’s needs. Visitors to the home are made to feel welcome. Staff morale at the home is good. The management team ensure that prospective residents are assessed prior to admission so that they are able to meet the individual’s needs. Residents are actively encouraged and enabled to participate in a range of activities, which meet their social care needs. Positive comments were also made about the food at the home. Residents and/or their representatives can raise concerns about the service freely and any complaints received are listened to, taken seriously an acted upon in a timely manner. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000018090.V353682.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.V353682.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs assessed prior to moving into the care home, so as to ensure that staff working within the care home are able to meet their needs and provide the appropriate care. EVIDENCE: The files of two recently admitted residents were inspected and evidence indicated that the management of the home completed a pre admission assessment prior to admission for both people, so as to ensure that they are able to meet the prospective resident’s needs. In addition to the formal assessment, additional information had been provided, by the individual resident’s placing authority. Care must be taken to ensure that information provided by individual’s placing authority is transferred/included in the pre admission assessment so as to ensure that this information is not lost and can be cross referenced to the care plan. This could lead to information being missed or not appropriately followed through. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 9 It was positive to note that since the last inspection, written evidence was available to indicate that the management team had formally written to the resident and/or their representative confirming that they could meet the person’s needs and for one person their representative had confirmed that they were happy with the outcome of the assessment. The home does not provide intermediate care. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Gaps in the recording of care management means that there may be times where the needs of residents are not always met. Aspects of medication administration at the home are unsatisfactory and could leave residents at risk. EVIDENCE: A random sample of three care plans, were examined in full at this inspection. It is clear that staff, at the home spend time and effort on care planning, and in general there was a good level of information available about individual residents to assist staff in providing care. Discussion with individual members of staff indicated that staff had a good knowledge and understanding of residents care needs, however information detailed within individual resident’s care plans, were not always observed to be followed consistently and this could compromise residents care. This refers specifically to poor manual handling procedures, which were carried out by senior/care staff during the inspection and not in line with information recorded Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 11 within individual’s care files. A care file was observed to not record that the resident required a handling belt for manual handling procedures and yet when questioned, a senior member of care staff advised the inspector that this item of equipment should be used. The manual handling procedure adopted by both members of staff, looked both uncomfortable and unsafe for the resident and cumbersome for staff. Care records show that further development of the management team’s care planning and risk assessment processes is needed. Staff need to ensure that individual resident’s needs are fully recorded and detail the interventions required so as to ensure that individual care plans for residents are detailed and comprehensive. Identified shortfalls in care planning were discussed with the registered provider/manager at the time of the inspection. Additional information is required identifying proactive measures for those people who have poor dietary requirements and are at risk of falls. Particular attention must be afforded to those people who have a diagnosis of dementia and/or mental health issues and the care plan must include details of how this affects their daily living skills and provide sufficient strategies, which will enable staff to deliver care that is both proactive and able to meet individual’s care needs. Further consideration should also be given to ensuring that care plans highlight where residents are independent, so that skills are maintained and not lost. Daily care records were in general for most people written daily, however some gaps were noted. Inconsistencies were observed whereby some records were seen to be detailed and informative and others to contain basic information and not include staff interventions e.g. “has been OK today” and “has been fine”. The registered provider/manager was reminded that daily care records are a good source of information and if completed well should provide evidence of staff interventions and depict how individual residents spend their day. Risk assessments were not devised for all areas of assessed risk. Further development is required to ensure that risks to residents are minimised and appropriate management strategies are devised and in place to ensure residents wellbeing and safety. Where restrictions are imposed on individual’s freedom and choice, evidence of agreement with the resident and/or their representative must be formalised and recorded within individual’s plan of care. Records showed that residents have access to a range of health care professionals and services e.g. GP, Community Psychiatrist Nurse, Chiropody, Dentist, Optician, District Nurse Services etc. Pressure relieving equipment was available in the home, and several residents were observed to have air or pressure relieving mattresses on their beds. As part of this site visit, medication practices and records were checked. The registered provider/manager advised that he is responsible for booking in/returning of medication. Medication at the home is managed in the main Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 12 through the use of a monitored dosage system (blister pack). The medication round was observed and staff practices were seen to be unsafe and unsatisfactory. A senior member of staff was observed to administer medication to two residents on two separate occasions without observing and checking that they had taken their actual medication. Additionally from inspection of staff training records, it was evident that none of the waking night staff had up to date medication training and it was confirmed to the inspector that night medications are on occasions, pre-dispensed into pots in preparation for staff to administer to residents. Records in general were well maintained and managed, however the registered provider/manager was advised to ensure that where the MAR (Medication Administration Records) states the dose to be administered can be variable, the specific dose administered should be recorded. Additionally where the MAR sheet has recorded `R`(refused) consistently for a period of time, information should be recorded as to what steps have been undertaken by the management team to seek advice from the resident’s GP and/or request a medication review. Some MAR records indicated that these had not been signed by the registered provider/manager to indicate that medication received was accurate and correct. The registered provider/manager was also advised to ensure that where packets/bottles of medication are started, these should be signed and dated when opened. A packet of tablets was handed to the registered provider/manager, as the box of medication had no label depicting the name of the person it was prescribed for or the prescriber’s instructions. A list of those staff deemed competent to administer medication was available. Out of nine members of staff, no evidence for one person was available as to when they last received medication training. This must be reviewed to ensure that all staff to administer medication had the necessary skills/up to date training to ensure positive outcomes for resident’s. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 13 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 social care needs of residents, are met and ensures that residents receive stimulation and appropriate activities. Meals provided to residents are of a satisfactory quality and promote a suitable diet and wellbeing for people at the home. EVIDENCE: An activities co-ordinator is employed at Hollywood Rest Home, five days a week between 13.00 p.m. and 17.00 p.m. The inspector was advised that a weekly activities roster is devised and implemented. On inspection of the activities roster, this evidenced activities, such as flower arranging, cards and puzzles, bingo, dancing, film afternoon, arts and crafts, bowling, quoits, singa-long, dominoes and other board games are provided. On inspection of the `activities ideas folder`, information relating to picture bingo, arts and crafts and bingo lottery were available. The registered provider/manager was advised to consider other activities such as enabling individuals to assist/get involved with day to day tasks around the care home (laying the table, folding napkins, making a bed etc) so that individuals may gain a level of satisfaction, achievement and self worth. Additionally staff could consider putting together a Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 14 memory box and/or life story-book for individual residents, which may help with drawing out memories. Social assessment forms were completed for the majority of residents, however for three residents no information was recorded pertaining to there past hobbies and present interests/personal preferences. Individual records indicated that social activities are recorded on a daily basis, depicting the names of those people who have participated and the type of activity undertaken. Residents spoken with confirmed that activities are available each day and one resident stated, “there’s much more to do here”. During the inspection residents were observed to engage in bingo, indoor bowls and listening to music. The Annual Quality Assurance Assessment details that within the next 12 months, the registered provider/manager aims to purchase a mini-bus, so as to enable residents to access community based activities more frequently. Visiting at the home is open and although there is no specific visitor’s room available, there are a number of spaces in the home where visits can take place in private. Information on advocacy services was on display in the home. Menu’s at the home are devised on a weekly basis and indicated that residents are provided with two choices at both the lunchtime and teatime meals. On the day of inspection, the lunchtime meal was observed to look plentiful and appetising and residents spoken with were positive about the food provided. The registered provider/manager was advised to consider offering bread/butter and/or potatoes with salads. Upon arrival to the care home, inspectors noted that the menu board in the dining room still displayed the choice of food from two days earlier. The registered provider/manager was advised that this could be confusing for some residents and was also asked to consider the devising of a larger print/pictorial menu so as to enable residents to make an informed choice. Inspectors noted that no hot drinks/biscuits were offered to residents during the day, however cold drinks were readily available and encouraged. The registered provider/manager was advised that throughout the day, staff provided inspectors with a choice of hot drinks, yet this same consideration was not afforded to those people who live at the care home. In general those residents who required assistance by staff to eat their meal, were provided with appropriate support and encouragement, however attention must be given to ensure that staff engage verbally with residents and advise them of what they are doing. This refers to one member of staff stopping to assist one resident with their meal so as to attend to another resident, who was not in the lounge area. The resident was not given any explanation as to where the member of staff was going or why they had stopped assisting them with their meal. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 15 Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 16 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. Concerns raised by others are managed appropriately to ensure that resident’s safety and wellbeing is maintained. Residents are protected by staff’s awareness and understanding of safeguarding procedures and policies. EVIDENCE: Hollywood Rest Home has a clear complaints policy and procedures in place. Inspectors noted that the complaints procedure was not displayed. The registered provider/manager advised that this is usually displayed however there are some residents who like to take items off the notice board. The management teams complaint file showed that residents and other’s concerns are recorded, detailing the specific nature of the complaint, investigation undertaken, action and outcome. On inspection of relatives’ surveys, these confirmed that people know how and to whom they can make a complaint and that they felt confident in raising concerns with the registered provider/manager and other members of staff. Since the last inspection one enquiry was received at both the Commission for Social Care Inspection and Thurrock Social Services relating to a possible safeguarding issue. The issue was investigated by the local social services department and the management of the home, were seen to act properly and Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 17 promptly. The training matrix evidenced that several members of staff had received training relating to challenging behaviour. Staff spoken with demonstrated an understanding and knowledge of safeguarding procedures. The training matrix indicated that the majority of staff working at the care home have received training relating to safeguarding, however not all staff have completed this training and this should be addressed. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hollywood Rest Home provides a comfortable, safe and homely environment for residents. EVIDENCE: As part of this inspection a tour of the premises was undertaken. The registration of the home has altered and the number of residents who can reside at the care home has increased from 21 to 27 people. Extensive improvements have been made both externally and internally to the property. This has resulted in the creation of a large dining area and two large communal lounge areas on the ground floor. Individual resident’s bedrooms were seen to be personalised and individualised and residents are actively encouraged to bring in personal belongings. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 19 The laundry area has been renovated and upgraded and includes commercial washing machines/tumble drier. On the day of inspection the home was observed to be clean, tidy and odour free. No health and safety issues were highlighted at this inspection. The registered provider/manager was advised to consider providing blinds/curtains for the door in one communal lounge as the sun was observed to be very strong and residents were noted to get very hot and had no protection from the sunlight. The garden to the rear of the property is accessible for residents use. The Annual Quality Assurance Assessment details that within the next 12 months it is envisaged that further improvements will be made to the garden. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures do not fully protect residents and shortfalls in staff training mean that some staff are not able to meet the needs of the residents living at the home. EVIDENCE: The registered provider/manager advised that staffing levels at the care home remain at 4 members of staff between 07.00 a.m. and 22.00 p.m., 2 waking night staff between 22.00 p.m. and 07.00 a.m. or 09.00 a.m. and 1 sleep in person each day. In addition to the above there is a laundry person and cleaner employed between 09.00 a.m. and 13.00 p.m. Monday to Friday. A cook is employed between 07.30 a.m. and 14.30 p.m., however staff advised that this person is only employed Monday to Friday, and at weekends cooking arrangements fall on care staff. The registered provider/manager needs to ensure that whilst care staff, are undertaking additional tasks (cooking), care provided to residents is not compromised and residents wellbeing is not placed at risk. There is no rationale as to why this should happen and the catering arrangements at the home remain the same seven days a week. The registered provider/manager’s hours are supernumerary to the roster, however the deputy manager who has responsibility for care planning processes and systems within the care home has no supernumerary shifts. This is seen as Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 21 unhelpful and needs reviewing to ensure that time and effort can be afforded to care planning processes within the home. Staff rosters evidenced that in general staffing levels are appropriate to meet the needs of existing residents. It was positive to note on the day of the inspection that staff deployment and staff interaction with residents was generally much improved. A random sample of staff files, were inspected for those staff newly appointed since the last key inspection. The majority of records as required by regulation were available, however gaps were noted in relation to full employment histories not available for some people, no start date/reason for leaving previous employment recorded in all cases and no Criminal Record Bureau check (CRB) or evidence of a completed CRB application form for one person. The registered provider/manager was advised that current recruitment procedures are not as robust as they should be and have the potential to put residents at risk. The training matrix was observed to be well maintained and records showed that the majority of staff have undertaken training relating to food hygiene, health and safety, fire awareness, manual handling, safeguarding, dementia awareness and infection control. Some gaps were noted pertaining to ancillary staff who did not have training relating to safeguarding, manual handling and infection control. Training deficits were also noted in relation to some members of night staff who did not have training relating to administration of medication or dementia awareness and one member of night staff was observed to not have training pertaining to fire awareness and/or manual handling. The cook was observed to have no evidence of food hygiene training. The Annual Quality Assurance Assessment details that it is planned within the next 12 months that all staff will receive further advanced training in dementia. Induction records for newly employed staff indicated that these are not in line with Skills for Care. The registered provider/manager needs to ensure that staff, receive induction training and information when they start work at the home in order that residents receive proper and consistent care. Records indicate that 7 members of staff have attained NVQ Level 2, 2 members of staff have achieved NVQ Level 3, 1 person is currently undertaking NVQ Level 2 and 2 members of staff are undertaking NVQ Level 3. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 22 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well run and outcomes for residents are positive. EVIDENCE: It is evident at this inspection that the management team at Hollywood Rest Home are striving to make continued effort to both maintain and achieve progress with meeting regulations. In general terms the home is well run and is continuing to provide positive outcomes for residents in some key areas. It is evident that this can only be achieved if the registered provider/manager, deputy manager and members of the staff team continue to work cohesively together. Further development is still required in the area of care planning, staff recruitment, staff training and staff induction. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 23 A random sample of records relating to the home’s electrical system, passenger lift, hoists, gas system and fire equipment were inspected and deemed satisfactory. The registered provider/manager was advised that the portable appliance test certificate had expired in September 2006. Shortfalls were observed in relation to the limited availability of COSHH (Control of Substances Hazardous to Health) data sheets for individual items utilised at the care home. This needs to be reviewed. Since the last inspection the registered provider/manager has implemented strategies in place to monitor the quality of the service provided. Surveys have been forwarded to residents and their representatives and although the results from these have not been formalised, comments relating to the service/s provided were recorded. Comments were mixed and included “I like my dinners”, “I don’t like going to bed too early”, “I’d like to go to bed earlier”, “more choice, better bread and hotter dinners”, “I have a nice bedroom” and “I would like to go out to the pub and shops more and have a Guinness every night”. The registered provider/manager advised that the home is not responsible for individual resident’s monies. The registered provider/manager confirmed that staff meetings are held and the last meetings were held in September and June 07. Records indicate that care staff in the home are receiving regular supervision, however the deputy manager has not received a formal supervision from the registered provider/manager for some considerable time. Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Hollywood Rest Home DS0000018090.V353682.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Ensure each resident has a detailed and comprehensive plan of care, which clearly identifies their care needs so that staff are able to deliver appropriate care. Previous timescale of 21.7.07 not fully met. Ensure that safe moving and handling techniques are adopted at all times and that resident’s safety and wellbeing are not compromised. Ensure that risk assessments are devised for all areas of assessed risk. This will ensure that risks are minimised and residents’ wellbeing are safeguarded. Ensure that safe and appropriate procedures are adopted by staff at all times in relation to administering medication to residents so as to ensure their wellbeing. Ensure that robust recruitment procedures are adopted so as to protect residents. Ensure that all members of staff receive training appropriate to DS0000018090.V353682.R01.S.doc Timescale for action 14/02/08 2. OP7 13(5) 03/12/07 3. OP7 13(4) 03/12/07 4. OP9 13(2) 03/12/07 5. 6. OP29 OP30 19 18(1)(c) (i) 03/12/07 01/03/08 Hollywood Rest Home Version 5.2 Page 26 the work they are to perform so as to deliver appropriate care to individual residents and meet their needs. Previous timescale of 1.5.06, 1.10.06 and 1.11.07 not fully met. Ensure that an appropriate system is provided to review the quality of care at the home and includes all interested parties (residents, their representatives, care staff and visiting professionals). Ensure that all staff working at the care home are appropriately supervised. This refers specifically to the deputy manager. Previous timescale of 1.8.07 not met. 7. OP33 24 01/03/08 8. OP36 18(2) 01/02/08 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. 2. 3. 4. 5. Refer to Standard OP7 OP7 OP15 OP15 OP38 Good Practice Recommendations Daily care records should be written daily and contain informative information depicting how individual residents spend their day and staff interventions. Any restrictions imposed on residents should be agreed with the resident and/or their representative and detailed within their individual plan of care. Consider devising the menu in larger print and/or pictorial. Ensure that all residents receive a choice of hot and cold drinks throughout the day. 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.V353682.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: 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 DS0000018090.V353682.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. Re-publishing this information is in breach of the terms of use of that website. 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