Inspection on 09/06/05 for Hollywood Rest Home

This inspection was carried out on 9th June 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 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 15/06/06

Hollywood Rest Home 17/11/05

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 Unannounced Thursday 9th June 2005 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 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 I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hollywood Rest Home Address 34 Cresthill Avenue Grays Essex RM17 5UJ 01375 382200 01375 381611 dillon-rs@hotmail.uk.com Mr Rajpaul Singh Dhillon Telephone number Fax number Email 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 CRH Care Home 17 Category(ies) of OP Old Age (17) registration, with number of places Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Old age, not falling within any other category (17) Date of last inspection 21st January 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 I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out by two inspectors, Michelle Love and Bernadette Little. The inspection took place over seven hours. At this visit a tour of the premises took place and some care records and staff employment files were inspected. At the time of the visit the registered manager/provider, the deputy manager, four members of staff and four residents were spoken with. No visitors were observed to visit the home at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 6 The home must ensure that all residents have things available to keep them occupied, both within the care home and within the local community. Both basic and specialist training must be provided to all staff working at the care home. All staff working at the care home should receive regular supervision. The registered manager/provider must ensure that he has scheduled time off duty each week. In addition the registered manager/provider must reduce the high number of hours worked by him to an appropriate level. The registered manager/provider must ensure that residents monetary records are accurate and kept up to date. 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 I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 4 and 5 Arrangements have been made to ensure that residents are assessed prior to admission and information from placing authorities sought and included. It is unclear as to whether prospective residents are given information and have the opportunity to visit the home prior to admission so as to make an informed choice as to whether or not Hollywood Rest Home is a care home they wish to live in. EVIDENCE: Pre Admission Assessments were completed for the newest residents to be admitted. Assessments and information from residents placing authorities were completed in advance of the residents being admitted to the care home. Two residents were unclear as to whether or not they had received a copy of the homes Service Users Guide prior to admission. Residents were noted to have a signed and dated Statement of Terms and Conditions. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 and 11 The care planning process has improved since the last inspection. Care plans have been reviewed and provide a good basis for care to be delivered to residents. Medication at the home is well managed and storage and records were seen to be appropriate. The systems for resident/representative consultation remain limited with little evidence to indicate that resident’s views are sought. EVIDENCE: Since the last inspection individual care plans and risk assessments sampled contained more detailed evidence of resident’s health, personal, emotional and social care needs. Information related to healthcare issues, visits and professionals involved were clearly documented. Information pertaining to funeral arrangements for residents were clearly detailed within the care plan. Staff spoken with demonstrated a good awareness of resident’s needs and abilities. Little evidence was available to indicate that residents had been involved within the care planning process. Information pertaining to funeral arrangements for residents were clearly detailed within the care plan. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 10 Medication records, storage and procedures were appropriate. Since the last inspection a homely remedy policy/procedures have been devised. Additional information is required specifying those homely remedies used at the care home. Medication training updates are required for some staff. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Activities within the home and local community are fairly limited for residents. The meals are good offering both choice and variety. EVIDENCE: Records indicate that since the last inspection there has been little opportunity for residents to receive meaningful stimulation and occupation within the home. In addition, little evidence suggested that residents have the opportunity for activities within the local community. No members of staff have received training in relation to `activities`. Since 26.1.2005, records indicate that on eight occasions activities were provided to some residents e.g. reading newspapers and magazines, listening to music, external entertainers visiting the home, colouring and walking in the garden. At the time of the inspection the local library were seen to visit and replenish the homes stock of books for residents. Residents were offered the choice of two meals at lunchtime. Food provided to residents looked appealing and plentiful and residents comments were complimentary. Care staff provided appropriate care, support and sensitivity to residents during the lunchtime meal. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 The homes Complaint and Adult Protection Policies and Procedures were appropriate so as to ensure that residents are protected from harm or abuse. Some complaint records/processes were incomplete. Staff have knowledge and understanding of Adult Protection issues which protects residents from abuse. EVIDENCE: The home’s Complaints Procedure was displayed within the main hallway. Since the last inspection the home has received one complaint. Records detailing the investigation undertaken, action taken and outcomes were not available. The majority of staff had not received training pertaining to Protection of Vulnerable Adults. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 standard(s) 19 Building works continue to be in progress at Hollywood Rest Home. Several areas within the home will be renovated and decorated as part of the home’s continuing refurbishment. EVIDENCE: Five additional bedrooms for residents are not ready for occupation. The registered providers stated that works should be completed within two months. Since the last inspection lockable cabinets for residents monies and valuables have been purchased. Furniture within one resident’s bedroom was of poor quality. No door handles were available on one resident’s sink cabinet. Two bedrooms did not have a plug for their sink. One hot water tap was observed to emit cold water instead of hot water. Residents have access to a range of specialist equipment such as walking frames, wheelchairs, bedrails and protective covers, hoist and slings. One bedrail was seen to have a substantial gap between the bedrail and mattress, which could pose a health and safety risk to the resident. Privacy screens within shared bedrooms offered little privacy for residents. Room 6 emitted a very strong and unpleasant odour. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 14 Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staffing levels at the home remain appropriate for the needs and numbers of residents. Since the last inspection the standard of recruitment practices within the home has improved so as to offer protection to those people living at Hollywood Rest Home. Staff training for staff remains poor. The home’s induction process is considered inadequate. The registered managers hours remain excessive. EVIDENCE: Staff rotas showed that agreed staffing levels are being maintained. The rotas provide evidence that from 16.5.2005 to 9.6.2005 inclusive the registered manager did not have a day off and week commencing 16.5.2005 worked a total of 64 hours, 23.5.2005 worked a total of 71 hours and 30.5.2005 worked a total of 66 hours. Recruitment records were organised and much improved. Since the last inspection two new members of staff have been recruited to the care home. No Criminal Record Bureau check was available for the visiting hairdresser or chiropodist. Staff training records evidenced that the majority of staff require mandatory training/updates and some specialist training which meet the specific needs of residents. The deputy manager and one senior member of staff are scheduled to receive four days of training relating to continence, diabetes, pressure sore care etc. The home’s induction format is not detailed and needs to be Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 16 progressed for the future. NVQ training for care staff, senior staff and the deputy manager is progressing well. The registered manager stated that NVQ Level 4 will not be achieved by June 2005, but hopefully by the end of December 2005. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 36, 37 and 38 Much effort has been undertaken by both the registered manager/provider and deputy manager to ensure that residents’ needs are met wherever possible. Staff have not received a regular programme of supervision. The home’s monetary arrangements for residents is not appropriate. EVIDENCE: Since the last inspection no management changes have been made at the care home. Much improvement has been undertaken since the last inspection to address previous identified shortfalls. Since May 2004/August 2004, staff have not received regular supervision by the registered manager/deputy manager. A random sample of records as required by regulation were inspected. Some gaps were noted pertaining to recording of fire drills for staff, the home’s hoist Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 18 had not been serviced since July 2004 and the passenger lift safety inspection had not been undertaken since July 2004. Records for water temperatures were unavailable on the day. Information on this can be obtained in the booklets “ Essential Information for providers of residential accommodation” and “A guide for employers” on 01787 881165 or at www.hsebooks.co.uk Resident’s monies are held by their placing authority for safekeeping. Records evidenced that the registered manager/provider is owed lots of money for individual residents by the different local authorities. One resident’s monetary record did not tally with monies held within the home. No individual receipts were available for chiropody and hairdressing. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 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 1 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 2 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x 2 1 2 2 Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 20 YES 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 OP12 and OP13 Regulation 16(2)(m) Requirement The registered person must ensure that residents are consulted regarding their individual preferences, likes and dislikes pertaining to activities and social interests. A regular programme of meaningful activities and occupation must be available for all residents. Previous timescale of 01.03.05 not met The registered person must ensure that suitable arrangements are maintained for satisfactory standards of hygiene in the care home. This refers specifically to the care homes kitchen. This standard was not inspected on this occasion. Ensure that persons employed at the care home have training appropriate to the work they perform and are suitably qualified and competent. This refers to the homes cook. Previous timescale of 01.05.05 not met Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 21 Timescale for action 30.09.05 2. OP15 16(2)(j) and 23(2)(d) Carried forward to next inspection 3. OP15 18(1)(a) and (c) 30.09.05 4. OP18 13(6) 5. OP27 18(1)(a) Ensure that all staff receive training pertaining to abuse, so as to prevent residents being harmed/at risk. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of residents. This refers to the registered person working between 60-70 hours per week without appropriate time off duty. Previous timescale of 01.03.05 not met Ensure that all staff working at the care home receive training appropriate to the work they are to perform. Ensure that all staff are supervised. Ensure that all records as required by regulation are up to date and available for inspection. 30.09.05 07.07.05 6. OP30 18(1)(c) 30.09.05 7. 8. OP36 OP37 and OP38 18(2) 17(1), 17(2) and Schedule 2/4 01.07.05 01.07.05 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 OP5 OP15 OP16 OP19 Good Practice Recommendations Ensure that evidence is recorded detailing whether residents and their representatives have visited the home prior to admission/had a trial visit. Ensure that the soap dispenser is filled for staff to use. Ensure that details of any complaint includes information relating to the investigation, action taken and outcomes. The registered person must notify the Commission so that a re-inspection can be completed prior to residents residing in new bedrooms. I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 22 Hollywood Rest Home 5. 6. 7. OP28 OP31 OP35 50 of staff should attain NVQ Level 2 in care or equivalent by 2005. The manager should obtain a qualification of NVQ Level 4 in Care and Management by 2005. Ensure that monetary records for residents is up to date and receipts available. Hollywood Rest Home I06 I56 S18090 Hollywood Rest Home V230248 090605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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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