Inspection on 11/04/07 for The Hollies

This inspection was carried out on 11th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Hollies 09/04/09

The Hollies 27/06/06

The Hollies 25/01/06

The Hollies 10/05/05

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 Hertfordshire EN10 7LG Lead Inspector Pat House Unannounced Inspection 11th April 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies DS0000019572.V336284.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. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 11 St Catharines Road Broxbourne Hertfordshire EN10 7LG 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) 01992 445044 01992 446911 Shawlmist Ltd Mr Ronald Hollywood Ms Linda Phipps Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2006 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, which leads on to a mature garden. The home’s Statement of Purpose and Service User’s Guide are available at all times and can be obtained from the office. Currently fees for the home range from £390 to £478 per week. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day with one inspector. The manager was present throughout the visit. Residents and staff were spoken with and the mid-day meal was served during the inspection. A selection of records was checked and residents’ care plans were tracked after the people concerned were spoken with. What the service does well: What has improved since the last inspection? What they could do better: No requirements have been made as a result of this inspection. One or two areas where it was felt improvements might be made had already been identified and were already being planned by the manager. The dispensing pharmacist will be contacted to request that medication records are pre-printed and sent regularly to the home, to ensure accuracy and the safety of medicine administration, although the present system in the home is thorough and no errors were found. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 6 New declaration forms will be sent to any agencies used so that it can be established that all recruitment checks and training have been completed for the agency staff used. It is advised that the present situation, where care staff walk through the kitchen to the staff room, is checked again with the Environmental Health Officer, although it appears that no concerns have been raised by the officer about this situation. 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. The Hollies DS0000019572.V336284.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 The Hollies DS0000019572.V336284.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): 1,2 and 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given detailed information and have full assessments completed before entering The Hollies to ensure that the home provides the services, which can meet their individual needs. EVIDENCE: The home has an up to date Statement of Purpose and Service User’s Guide which give clear information about the home and which are provided for all residents and prospective residents. Copies are available in the office and were also provided during the inspection. The information includes the Complaints Policy and a written contract, which has all appropriate details included. All prospective residents have detailed assessments completed by senior staff from the home before a place is offered and the manager obtains care summaries from any referring agencies. This information ensures that the The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 9 home is suitable to provide services for the individual who is considering living there. The Hollies DS0000019572.V336284.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): Standards 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good recording procedures ensure that care staff are able to be clear about how to meet individual needs and the systems for administering medication and for providing care ensure that service users are protected and treated with respect. EVIDENCE: A selection of care plans was tracked after the individuals concerned were spoken with. Good levels of information were recorded and residents or relatives signed most plans. Assessments for Moving and Handling, for bathing and for the risk of skin damage were all in place and body charts were included where appropriate. Regular reviews were documented and also signed. The risk of falls for residents are assessed by senior care staff and the bedroom of one lady who had had recent falls, had been rearranged to provide more safety and an alarm mat had been fitted. A new format for some of the risk The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 11 assessments is being introduced and these forms are clear and contain meaningful details. None of the present residents have any pressure sores and care staff said that they worked closely with District Nurses and the Continence Adviser to provide appropriate care for all people. Two residents are currently using specialist mattresses and one person, who is very deaf, confirmed that they had seen “every specialist possible” to help their hearing. Care staff now communicate with this resident using pad and paper, and the resident said this process worked well. Residents spoken with said that call alarms were answered quickly by staff and a list showing the key worker for each group of residents was seen displayed. Medication administration and storage was checked and no errors were found. Copies of prescriptions issued by the G.P. are now being kept and dates of opening for medication not provided pre-packed were seen on packaging. The home has a new metal drugs storage cabinet, which is fixed to the wall. Daily storage temperatures were being recorded, and the temperature was checked during the visit. All temperatures were at safe levels. There are detailed records kept of all medication received and administered in the home, and these were accurate and audited. It was however recommended that the pharmacist pre-print these record sheets to avoid the possibility of any written recording error. A new book for the records of controlled drugs should also be introduced which has numbered pages to ensure accuracy. Residents spoken with confirmed that all staff treated them with dignity and respect and always provided personal care in an appropriate way. Residents said that visits from health professionals always took place in private and that any visitors were made welcome at all times. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Service users enjoy living in the home where appropriate activities are provided and where visitors are welcomed. Residents can choose food from well-balanced menus and meals are nutritious and help to maintain everyone’s well-being. EVIDENCE: Staff arrange a weekly programme of activities for the residents. Some ladies spoken with in the lounge said that there was usually a weekly activity plan displayed, so they knew what was arranged. Weekly events include a visit from a volunteer who arranges a knitting and craft session and residents confirmed that they have newspapers delivered and have regular visits from the hairdresser. Each resident has details of their history and preferences noted and records are kept of which activity each person attends. Some residents spoken with said that they preferred to spend time in their own rooms and said that they were supported to make their own choices about how they spent their days. Some residents managed their own finances, to varying extents, but mostly families had control of their money. The proprietor is the The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 13 appointee for one long standing resident and this situation has been checked at previous inspections. Residents spoken with said they usually enjoyed the food provided and that there is a choice of food available for each meal served. All residents had cups of tea beside them at the beginning of the inspection and drinks were available all day, in the communal rooms and in bedrooms. There are two chefs employed, one of which just works at weekends. The chef on duty was wearing protective clothing during the visit and records of food temperature checks and individual food consumption were being kept. There have been regular visits from the Environmental Health Officer and no requirements are outstanding from these inspections. However, it was noted that there is no door between the kitchen and the connecting staff room, and that care staff regularly walk through the kitchen to the staff room and to leave the building. It may be advisable to provide protective clothing for staff when they walk through the kitchen, but it was accepted that the Environmental Health Officer has not seen the present arrangements as a problem. Further contact with this officer may be advisable to ensure procedures are all correct. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that any concerns they might have will be listened to, and the procedures in place ensure that all residents are protected from abuse. EVIDENCE: Written policies on Complaints, Adult Protection and Whistle Blowing are in place, and information about these are included in the induction training for all members of staff. All staff have also attended specific training in Safeguarding Adults (Adult Protection) and the manager said that updates to this training will be on-going. Some residents said they were aware of the procedure for making a complaint and all those spoken with said they would not hesitate to tell staff if they had any concerns. Any complaints are documented along with any resulting actions. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home which is well maintained and where good hygiene standards help to protect both residents and staff. EVIDENCE: The home was bright and clean on the day of the visit and residents spoken with said that all areas of the home were kept “spotlessly clean”. A new carpet had been laid in the conservatory and a repair had been ordered for the call button on the lift door. The hot water delivery was checked in selected areas and was being provided at safe temperatures. Some rooms have magnetic door closures fitted and no fire doors were being wedged open. The gardens looked attractive and residents said they were looking forward to going outside in the summer. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 16 The home has a macerator for dealing with waste products and, as a result, the manager said there was no need for staff to use red alginate bags for soiled laundry. Staff said there were always supplies of disposable gloves available and that all staff had been vaccinated against Hepatitis B infection. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs met in an appropriate way by well trained staff and the procedures for recruiting staff, and planned changes to documentation, help to ensure all residents are protected EVIDENCE: Residents spoken with said they felt there were always enough staff on duty and praised the care that staff provided. The interaction between staff and residents was observed and it was clear that care workers knew the individuals well and that there were very good relations between service users and the staff team. The manager has a recorded overview of staff training and individual mandatory training is kept up to date. All staff have had recent training in Moving and Handling, Dementia and Adult Abuse and most have completed First Aid training. More courses are booked including a certificated Medication Administration course for senior staff. Care staff confirmed that they are encouraged to do NVQ training and numbers of staff who have completed this training will be checked at the next visit. A selection of staff records was examined and evidence was seen that all appropriate recruitment checks were in place before the individuals started The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 18 work. Some application forms needed more detail of employment history and the manager said this area would be thoroughly checked in the future. However, more detail was needed from the agency used to ensure that all temporary staff have the relevant checks and training completed and the manager said a new declaration form would now be sent for completion with all requests for agency staff. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 19 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): Standards 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run for the benefit of the residents whose views are regularly sought. Procedures followed ensure that both residents and staff have their welfare and safety protected. EVIDENCE: Staff and residents spoken with praised the home’s manager and said that the running of the home was open and took into account individual views. The manager is registered with the CSCI and has completed the Registered Manager’s Award. A written Quality Assurance policy is in place and questionnaires are regularly sent to residents, families and other stakeholders. Residents spoken with confirmed they had been given questionnaires and that their views about meals and activities were also sought. The manager uses The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 20 results of the questionnaires and from monitoring other records to plan any changes needed in the home and sends written results to families. The fire officer had visited the home in March and all recommendations from this report had been actioned. The fire records were up to date and staff confirmed there were regular fire drills in the home. The accident book was properly documented and general risk assessments had been completed, including those for the electric recliner chairs in use. Some bedroom windows did not have window restrictors fitted and the manager said she would check that appropriate risk assessments were up to date for these and for the uncovered radiators. The manager is also developing new Infection Control and Falls Prevention policies for the home. The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 21 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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 The Hollies DS0000019572.V336284.R01.S.doc Version 5.2 Page 24 - 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!