Inspection on 10/05/05 for The Hollies

This inspection was carried out on 10th May 2005.

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.

Other inspections for this house

The Hollies 09/04/09

The Hollies 11/04/07

The Hollies 27/06/06

The Hollies 25/01/06

The Hollies 17/01/05

The Hollies 25/06/04

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 The Hollies 11 St Catharines Road Broxbourne Herts EN10 7LG Lead Inspector Judith Kent Unannounced 10 May 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. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Hollies Address 11 St Catharines Road, Broxbourne, herts, EN10 7LG 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) 01992 445 044 01992 446 911 Shawlmist Ltd Ms Linda Phipps CRH Care Home 27 Category(ies) of Older people aged 65 or over registration, with number of places The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 17 January 2005 Brief Description of the Service: The Hollies is a large Tudor-style Grade II listed building that is located in a quiet residential area of Broxbourne. It was converted to its present use as a care home in 1984. It offers residential accommodation to a maximum of twenty-seven elder people and there are bedrooms on each of the three floors, served by a passenger lift. There are local shops, a Post Office, bank and pharmacy nearby. Public transport is available a short distance away and the home is equidistant from the town centres of Hoddesdon and Broxbourne. Accommodation is provided in nineteen single occupancy bedrooms and four double bedrooms. There are two lounges, a dining room and a conservatory that leads on to a mature garden. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted between 10.15 a.m. and 2.45 p.m. by two inspectors. There were twenty-four people living at the home at the time of the inspection. The inspectors toured the home and spoke to eight residents and two members of staff plus the manager and her deputy. Some records were looked at. There were two requirements made in the last report with timescales to be met beyond the date of this inspection – these will be looked at more closely at the next inspection. One requirement in respect of pre-employment checks had again not been met and is once more included in this report. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that the legally required checks are made and confirmed before staff start work in the home to ensure the safety of service users who live there. The recording of activities, outings etc that take place both in- and outside the home would help to give a clearer picture of service users’ lives. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 6 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 Hollies I52 s19572 The Hollies v225784 100505 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 The Hollies I52 s19572 The Hollies v225784 100505 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) 3 The home offers a place only to people for whom an assessment has been made, either by the commissioning organisation (usually social services) or by the home itself. The process ensures that the home is able to meet each person’s assessed needs. EVIDENCE: Pre-admission assessments are completed either by a social worker or by a member of the home’s management team and a copy is held on each Service user’s file. The assessments inform the care plans which set out each person’s care needs and how they are to be met. The Hollies I52 s19572 The Hollies v225784 100505 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 The home provides a service that takes account of individual health and care needs and ensures that they have access to appropriate health services. Service users’ personal care is managed discreetly in most instances, although the need to respect dignity should be brought to the attention of the staff team. EVIDENCE: The care plans seen at the inspection were generally in good order although there were dates and signatures missing on some documents. Pre-admission assessments and risk assessments were in place and monthly reviews had been recorded. Visits and interventions by health professionals, e.g. GPs, district nurses, hospital consultants etc, are noted on service users’ daily records and are transferred to care plans. One care plan noted that the community dietician had been called in to give advice and guidance about a service user who was eating very little, although there was no apparent weight loss. There was no monitoring record of the service user’s eating pattern and it was suggested at the inspection that this should have taken place. None of the service users manage their own medication. The deputy manager takes responsibility for medication in the home and has devised a system of The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 10 auditing which helps her to maintain accurate recording and administration of medication. A random sample of the Medication Administration Record (MAR) sheets were checked along with the medication held – these had been accurately completed except for one instance where there were two paracetemol tablets unaccounted for. Only those staff who have received appropriate training are authorised to give medication and the deputy outlined the content of her training course, which covers all aspects of medication including why records must be accurate, side effects of drugs, signs to be aware of. The inspectors did not see medication being given out at this inspection. One serious incident of disregard for service users’ privacy and dignity observed by the inspector was drawn to the manager’s attention so that she can reinforce to care staff the need to be aware of service users’ rights. The risk presented to service users by care staff with long fingernails was also discussed with the manager. The Hollies I52 s19572 The Hollies v225784 100505 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 & 15 Service users are able to make decisions about how they wish to live at the home and enjoy well-cooked and nutritious meals. Visitors are welcomed into the home at any time. While the visiting entertainers to the home are much enjoyed, service users would benefit from more involvement in activities in the home. EVIDENCE: Pre-arranged group activity sessions, led by visiting entertainers, were noted in the activity diary, but service users’ files showed few records of activities that they had taken part in, although the manager said that care staff engage service users in unplanned one-to-one activities such as manicures, sing songs etc. Inclusion of this information on daily care records would help to give an all-round picture of people’s lives in the home – this course of action was recommended in the last inspection report. The manager had contacted the National Association for Providers of Activities for Older People (NAPA) as recommended at the last inspection One care worker said that there were not many activities offered recently and that she would like to see more. Two service users spoken with said that staff have no time to spend chatting with them - one expressed an enjoyment of a game of cards or dominoes but said that there is no-one to play with her. In view of these comments from both staff and service users there is scope for increased staff involvement in planning and carrying out activities. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 12 There was a requirement in the last inspection report that a programme of activities should be developed and carried out, with a timescale of 31st May 2005 and this will be looked at during the next inspection. Service users are able to receive visitors at any time and can entertain them in their own rooms or in the communal areas of the home. Visitors to one service user appeared to be on good terms with the home staff. Service users were mostly satisfied with the catering at The Hollies, although one person said that the food ‘is not so good now’. Examination of the menus showed that they were varied and nutritious, and although there is no set choice to the main meal of the day, an alternative can always be arranged. At least one fresh vegetable is offered every day and the kitchen is able to cater for special diets. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 13 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 & 18 Service users or their relatives would have sufficient information to make a formal complaint to the home which would be dealt with appropriately. The home’s adult protection procedures and training given to staff should protect service users from harm. EVIDENCE: The home’s complaints procedure meets the criteria set out in the National Minimum Standards and is given to all service users/relatives. There have been no complaints recorded since the last inspection. The home has policies on whistle-blowing, restraint and abuse and staff are given training and information. The Hertfordshire County Council Adult Protection handbook is available to all staff. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 14 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 & 26 The home provides a safe, clean and well-maintained environment and is in good decorative condition generally. EVIDENCE: The home is maintained to a good standard by the proprietors who spend a lot of time there and who carry out the great majority of the maintenance and repairs themselves – indeed when the inspectors arrived, they were in process of replacing and making safe a door threshold into the dining room. A tour round the home found both the communal areas and service users’ rooms to be clean and odour-free. There were personal touches to be seen in each room reflecting individual taste. The ground floor hall and stair carpet has recently been replaced and the home gives a welcoming impression. The Hollies I52 s19572 The Hollies v225784 100505 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, 29, 30 Service users at The Hollies can be confident that the care staff have, or are in the process of acquiring, the competences needed to care for them as they would expect and that the home offers refresher training to staff to ensure that their skills are maintained and their knowledge of care practice is enhanced. At the time of the inspection the home could not be sure that all care staff were suitable to be working with vulnerable people as the necessary checks had not been completed before they started work. EVIDENCE: The manager has developed an induction and foundation training package based on the Skills for Care model, and keeps records of competencies achieved by the care staff, who are then encouraged to take the National Vocational Qualification (NVQ) in Care Level 2. Other relevant training has also been given, e.g. understanding and caring for people who have dementia. One careworker spoken with said how well she was being supported in her training by both the staff group and the managers. Staffing levels are maintained at four careworkers during the morning reducing to three during the rest of the day. Service users spoke well of the staff saying they were ‘very nice’ and there were no adverse comments about them, although two people said that staff do not have time to spend talking with them. The home had recruited only one new member of staff since the previous inspection and the file showed that all the necessary documents and references were in place and that a check against the POVA list had been made before she started at the home. The Criminal Records Bureau (CRB) check had been received about eight weeks after she started work, but the manager confirmed The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 16 that during that time she had been working under the supervision of a senior careworker. However, the manager said that she was still having difficulties with obtaining both POVA and CRB checks and examination of records showed that some had been outstanding for several months, despite her follow-up action with the CRB. Consequently, some staff were working in the home without the necessary checks having been obtained. Discussion revealed that in some cases this was because the CRB applications had been incorrectly filled in or that information was missing from them. It was suggested to the manager that she check the forms with applicants at the time of completion to avoid unnecessary delays. She also confirmed that all those without CRB checks in place were working in the home under supervision. It was again reiterated that it is a legal requirement that the POVA and CRB checks must be in place for all staff working in the home and they are again the subject of a Requirement in this report. A telephone call was made to the manager two weeks after the inspection when she was able to confirm that POVA checks had been carried out and that all were now in place, although some CRB disclosures were still awaited. The Hollies I52 s19572 The Hollies v225784 100505 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) 33, 36 & 38 The quality monitoring survey which is currently in development, will give relatives and other stakeholders as well as service users the opportunity to express their thoughts about the service provided by the home. The health and safety of residents and staff are safeguarded by the home and both groups can be confident that they are living and working in a safe environment. EVIDENCE: There was a requirement in the last report that a quality monitoring system which meets National Minimum Standards was developed and the timescale for this was set at the end of July this year. The manager reported at this inspection that this is on target and that it should be completed within the time set. Records of checks on fire and moving and handling equipment were seen to be up to date. The home had had a recent visit by the fire service and the recommendations made by the fire officer had already been carried out. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 18 An environmental health officer had also recently visited the home and found it to be satisfactory - no recommendations had been made. Training in health and safety matters, e.g. moving and handling, fire safety, is given to care staff at induction and is updated at appropriate intervals. One of the domestic staff on duty said that she had had training on Control of Substances Hazardous to Health (COSHH) regulations and that she was aware of the risk assessments for these products. Records showed that staff receive regular supervision. The Hollies I52 s19572 The Hollies v225784 100505 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x 3 x 3 The Hollies I52 s19572 The Hollies v225784 100505 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 29 Regulation 19(4)(b) Requirement That satisfactory CRB and POVA disclosures are obtained prior to staff working in the home. (This was a requirement of the last two reports and has not been met) That service users dignity and privacy is respected at all times. That a programme of activities is developed, delivered and recorded. That the quality assurance system, which partially developed, is completed in accordance with this stamdard and regualtion. Timescale for action From 10.05.05 2. 3. 4. 10 12 33 12(4)(a) 16(2)(n) 24 From 10.05.05 By 31.05.05 By 31.07.07 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. The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 21 Refer to Standard 12 Good Practice Recommendations That residents records hold information about the activities they have participated in. Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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 The Hollies I52 s19572 The Hollies v225784 100505 Stage 4.doc Version 1.30 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!