Inspection on 11/08/06 for The Hollies

This inspection was carried out on 11th August 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hollies 13/02/06

The Hollies 24/10/05

The Hollies 16/12/04

The Hollies 29/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hollies (The) The Hamlet South Normanton Derby Derbyshire DE55 2JN Lead Inspector Angela Kennedy Key Unannounced Inspection 11th August 2006 01:30 Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 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 Hollies (The) DS0000020018.V298615.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 Adults 18-65. 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. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollies (The) Address The Hamlet South Normanton Derby Derbyshire DE55 2JN (01773) 580872 (01773) 812294 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) Prime Life Limited Lisa Jo-Anne Cummins Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one falling within category MD may be admitted into The Hollies Care Home where there are 21 persons already accommodated within the home. The maximum number of persons accommodated within The Hollies Care Home is 21 13th February 2006 Date of last inspection Brief Description of the Service: The Hollies is a purpose built care home set in its own landscaped garden. The home is not close to shopping areas but is a short bus ride from Alfreton, which offers a good range of facilities. The home provides accommodation for 20 younger adults with mental health needs. The Hollies provides staffed care, full board and a range of social and leisure activities. Service users have access to laundry and kitchenette facilities to promote independent living skills. The current scales of charges at the home per week are: £405- £700. Further information regarding the Hollies can be obtained by telephoning the registered manager. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and looked at all of the key national minimum standards. The inspection took place over a three and a half hour period. Additional time was spent in preparation for the visit, looking at previous reports and other documents relating to the history of the home. Two service users care files were looked at, these included care plans, risk assessment and other relevant records and documents that related to the service users care and support needs. Two staff files were seen, looking at the recruitment records and documents and training undertaken. Several other documents were examined including staffing rotas, menus, health and safety records, complaints records and the homes medication practices and records. Several of the service users were spoken with plus two members of staff. The registered manager was available throughout the inspection and supported a member of the senior care staff team who assisted the inspector with any documents required. What the service does well: The environment at the home was open and friendly, and the accommodation provided to service users was attractive and personalised to suit individual’s choice and tastes. A positive rapport was noted between staff and service users, this was observed in the staffs approach to residents and the relaxed and friendly conversations that took place. The hollies continue to maintain good administrative systems and structures. The records assessed were well maintained and up to date. The two service user files seen provided detailed support plans and risk assessments that demonstrated that a person centred approach to each service users care needs was undertaken. Hollies (The) DS0000020018.V298615.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. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users needs were assessed prior to moving into the home to ensure their needs could be met. EVIDENCE: A detailed needs assessment is undertaken by the service users social worker and the homes registered manager prior to admission, this assessment identified the personal support required, assessment and management of risk, cultural and religious needs, physical and mental health care needs, methods of communication, family and social contact and any specific condition related needs and service users day time activities, i.e.- education, employment or other occupational activities. This indicates that the Hollies has sufficient information prior to admission to determine if each individual’s needs can be met by the service. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users were consulted and involved in the development of their individual care plans and were supported to maintain their independence whenever possible. EVIDENCE: Two service user’s care files were examined and both had evidence in place to demonstrate that they had been involved in the development of their care plans. The care plans seen were detailed and informed staff how to support the service user in all aspects of their personal, social and the health care needs, and included information regarding; personal care, mobility, communication methods, cultural, spiritual and religious needs, eating and drinking, sleeping, dressing, activities and interests and managing finances. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 10 Care plans were reviewed with service user involvement and evidence was in place to support this. Chiropodists and opticians visited the home to provide foot and eye care as required and service users visited the dentist for dental checks as and when required. Community psychiatric nurses and other health care professionals were available to service users as required and according to assessed need. Within the two service user’s files seen records were also maintained regarding residents daily activities and general well being. Service users were encouraged to participate in the day-to-day running of the Hollies, and the policies seen were available in a pictorial format that was understandable to the service users. The registered manager confirmed that some service users had been involved in the selection process of new staff. Service users were kept up to date regarding any changes in staff and evidence of this was seen on the day of inspection. Service user meetings were held at the home on a regular basis and feedback was given about the outcomes of their involvement or participation. Risk assessments were in place that looked at identified risks and the action required to minimise these risks. Following risk assessments service users were supported to take reasonable risks, when possible, in order to maintain their independence. Assessments were in place that identified, mental health, behaviour, nutritional needs, sleeping, activities, mobility and relationships including family and friends. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users were supported to take part in appropriate activities both within the home and the community, and were able to maintain contact with family and friends and maintain their independence, individual choice and freedom of movement whenever possible. Meals at the home were nutritional in content and service users were involved in the choice of meals provided. EVIDENCE: The registered manager stated that none of the service users were in employment but confirmed that one service user was hoping to undertake some charity work. Three service users attend local support groups and/or day centres on a regular basis. Service users accessed local facilities and those spoken with confirmed that they went out to the local shops or nearby towns to do some shopping and would use public transport as required. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 12 Activities were available in the home and included. weekly quizzes, tabletop and board games, arts and crafts, DVD nights, theme days- St Georges Day, pet day, Irish clover hunt. Activities outside the home included, trips out to the local pub, bowls, cinema, swimming, day trips, including trips to the coast and safari park. The home had an open visiting policy and service users were able to entertain their visitors within their private accommodation if they wished. Daily routines within the home were flexible and service users were encouraged and supported to make decisions regarding their lives. Service users had keys to their private accommodation in order to maintain their privacy; staff did however hold a master key for all rooms in the event of requiring urgent access. Lockable facilities were available within private accommodation and some service users who chose to and were able, kept small amounts of monies within these facilities. Service users preferred name was also recorded within their personal care files. Service users were able to participate in cooking and other domestic tasks and were supported by staff in these activities as required. The home had recently employed a new chef and service users spoken with were very complimentary regarding the quality of meals provided. Service users were able to decide amongst themselves the variety of meals on the menu; the service users spoken with confirmed this. Meal times at home demonstrated flexibility, breakfast was available as required, lunch was between 12 and 1 pm, and evening meal was between 4.45- 5.15pm and supper at 9pm or as required. Service Users spoken with confirmed that they were happy with the meal times. Special diets were catered for as required, and evidence was in place to demonstrate this. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The personal, physical and emotional healthcare needs of the service users were met according to service users needs and preference. Medication practices at the home demonstrated that service users welfare was maintained. EVIDENCE: Evidence was in place within the two service users files seen to demonstrate that their health, physical and emotional needs were met by the home. Referrals to appropriate specialists were made as required and all service users were registered with a general practitioner and were supported to access health care facilities as required. Staff demonstrated a sensitive and respectful approach to service users. Daily routines at the home were flexible. This was confirmed by service users spoken with who said they were able to go to bed and get up as they chose and participate in activities if they wished to. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 14 All service users were allocated key workers who were responsible for ensuring care files were kept up to date. Service users spoken with were able to say who their allocated key worker was and stated they were happy with the support provided by their key workers. The medication practices at the home were inspected and were found to be satisfactory. All staff that administered medication had undertaken the appropriate training. Two service users self-administered their medication and risk assessments were in place to demonstrate that they had the ability to do so. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The complaints procedure at the home was clear and accessible to service users and robust procedures were in place which enhanced the protection of service users from abuse. EVIDENCE: The home’s complaints procedure was clear and included the timescales required for responding to complaints, and was accessible to service users, visitors and staff. A copy of the complaints procedure was also available and on display in pictorial format for service users who required this. Two complaints had been received by the home since the last inspection; both of these complaints had been dealt with and resolved within the required 28day timescale. Robust procedures are in place for responding and dealing with safeguarding adults issues, and the home’s safe guarding adults policy followed Derbyshire Social Services guidelines. Staff spoken with demonstrated a good understanding of safeguarding adults issues and the procedures that should be followed, if required. The Hollies and Derbyshire Social Services appointed manager had undertaken one safeguarding adult investigation and the action taken had been clearly recorded and evidence was in place to demonstrate that the home had acted appropriately and promptly to ensure residents safety was maintained. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 16 Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users lived in a homely and comfortable environment, which was clean and well maintained. Service users private accommodation demonstrated their individuality and promoted their independence. EVIDENCE: A tour of the building was undertaken and some of the service users private accommodation was seen and all had adjoining living areas. Of the rooms seen all were personalised with service users own belongings and furniture and demonstrated each individual’s preferences and taste. During the inspection process the service users spoken to were keen to show their private accommodation and confirmed that they liked their rooms. The original games room, which the registered manager stated was rarely used, had been converted into a flat for use by one of the service users and staff had supported this service user to furnish the room according to their personal taste and style. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 18 All service users had a key to their private accommodation. A new games area had been created at the home for service users use. The risk of fire identified at the last inspection, regarding the smoking habits of a service user within their private accommodation had been addressed and satisfactory safety practices were in place to reduce this risk. Shower rooms, bathrooms and toilets were seen and all provided adequate space and privacy for service users. The communal areas provided for service users were viewed and were bright, spacious and homely. Services users spoken with said they were happy with the accommodation provided, and were free to choose where they went within the home. The home had wheelchair access throughout and the garden area provided seating for service users. The laundry area of the home was seen and satisfactory and sufficient washing and drying facilities were in place to cater for service users laundering requirements. Policies and procedures were in place regarding infection control and staff had received training in this area. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The homes recruitment practice requires development to ensure service users protection is enhanced. Staff had received the appropriate training to ensure service users needs are met. EVIDENCE: Fifteen care staff were employed at the Hollies and of these six had a National Vocational Qualification (NVQ) in care at level 2 or above. One senior member of staff was undertaking the registered managers award. The home has not as yet achieved 50 of the care team holding an NVQ 2 in care. The recruitment practices of the home were examined within two staff files and had satisfactory criminal records bureau checks, two satisfactory references and the required identification documents. However the homes employment application form requested the applicant’s last 10 years employment history, rather than the required full employment history, with any gaps in employment being recorded. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 20 A training and development plan was in place at the home for staff and within the two staff files seen evidence was in place to support that training had taken place, this included; fire safety, food hygiene, moving and handling, care of substances hazardous to health, mental health training, adult protection training, first aid, food hygiene, psychological and physical intervention training, communication training, medication training and a national vocational qualification in care at level 2. Both staff spoken with confirmed that the training provided by the home was good and felt that it met the needs of service users. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home was managed efficiently and service users views were actively sought and influenced the running of the home. The health and safety practices of the home demonstrated that services users welfare was protected and promoted. EVIDENCE: The registered manager has been in post at the home for 6 years and has successfully achieved a management qualification. Both staff and service users spoke highly of the registered manager and stated that she was approachable and supportive. The quality assurance systems at the home where seen and discussed, and included, comments leaflets on display at the entrance for service users, visitors and staff, service users meetings held monthly, although often these were more recent if required, discussions and intervention regarding staff Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 22 recruitment, including staff interviews. feedback was provided to service users regarding any action taken that affected the running of the home. Service users spoken with confirmed that they were able to express their opinions regarding the running of the home and said that they felt their views were listened to. All service users spoken with said they were kept informed of any changes in the running of the home, such as staff recruitment. Some of the health and safety records of the home were seen and were in date these included, weekly fire checks, gas appliance service, fire fighting equipment service, water heating check for compliance with legionella, emergency call systems service, written assessment for control of substances hazardous to health (COSHH). Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 24 NO 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 YA34 Regulation 19 Schedule 2 (6) Requirement A full employment history, together with a satisfactory written explanation of any gaps in employment must be provided on the homes employment application form. Timescale for action 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations 50 of all care staff should achieve NVQ level 2. Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Hollies (The) DS0000020018.V298615.R01.S.doc Version 5.2 Page 26 - 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. 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