Inspection on 13/02/06 for The Hollies

This inspection was carried out on 13th February 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hollies 11/08/06

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 Gail Meads Unannounced Inspection 13th February 2006 09:15 Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 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.V285969.R01.S.doc Version 5.1 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.V285969.R01.S.doc Version 5.1 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 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 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 difficulties. The home 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. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a three hour period. Additional time was spent in preparation for the visit, looking at previous reports and other documents. During the inspection process a number of documents were examined, including residents’ care files, staffing rotas, menus and health and safety records, time was spent speaking to a number of residents, and to the manager. The inspector spent a specific amount of the inspection concentrating on the Standards which were not assessed during the last inspection dated 24/10/05 What the service does well: What has improved since the last inspection? The deployment of staff and staffing levels provided has improved since the last inspection dated 24/10/05 Staff now have more time to give one to one time with residents and more trips and activities are available although the manager stated that residents are generally difficult to engage in activities. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 6 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.V285969.R01.S.doc Version 5.1 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.V285969.R01.S.doc Version 5.1 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): These Standards were not assessed during this inspection as they were found to be satisfactory at the last inspection dated 24/10/05 EVIDENCE: Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 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): 10. Staff are aware of the need for confidentiality and adhere to the homes policy. EVIDENCE: Residents files are kept in a locked room at all times the computer can only be accessed with a ‘password’. Residents are made aware that they can have access to any information about themselves held by the home; there is a statement to this effect in the residents’ information guide. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 10 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): 15.16.17. Residents are encouraged to maintain contact with their relatives and friends where appropriate and safe to do so. Residents are given choices around self-medication and handling their own finances. The rights of residents are respected and residents are able to exercise their rights when appropriate. Residents are involved in the choice of food provided. EVIDENCE: Residents are encouraged to have contact with their family and friends, although this can be difficult at times when for a range of reasons it is not safe or appropriate to continue to maintain contact as this might put the resident at risk. The home has a policy in place about respecting residents right to engage in relationships sexual or otherwise, a number of residents have maintained their relationships whilst in the home and residents rights to privacy are respected. There are occasions where vulnerable residents are in danger of being financially or sexually exploited and there is evidence to demonstrate that these situations are taken seriously and appropriate advice and action is taken to protect such residents. Residents are encouraged to maintain their right to vote. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 11 Two residents self medicate however the manager stated that there were no residents at the time of the inspection capable of handling their own finances. To promote independence staff work with residents to enable them to be as independent as possible this involves residents having choices and residents do not always want nutritionally balanced meals, which can be difficult. The menus reflect a balance of good nutritional meals and the resident’s choices, which can tend to be snack type meals of pizzas, burghers and chips. There are three meals provided per day and residents have snacks and drinks available in the kitchenettes at any time. The dining area is well presented warm and light. The lunch period was observed and residents were relaxed and talkative. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 12 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): 20.21. Residents are encouraged to self medicate where appropriate and safe to do so. EVIDENCE: There were two residents who self medicate at the time of the inspection. The home has a policy for the care of residents when dying the manager stated that residents would be offered the identified care, the general practitioners advice and support would be sought and relatives/significant others would be informed and access would be given for family to visit at any time. The identified spiritual needs of the resident would be requested and respected. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 13 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): These Standards were not assessed during this inspection as they were found to be satisfactory at the last inspection dated 24/10/05 EVIDENCE: Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 14 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): 24.25.26.27.28.29.30. The environment is well maintained internally and externally. The home is suitable for purpose EVIDENCE: Each resident has a bedroom and adjoining lounge area provided the bedrooms assessed were reasonably tidy and clean, residents are encouraged to take responsibility for their own rooms, however where residents are not able to carry out these tasks staff will help and support residents to do as much as they are able. One residents room assessed on the day of the inspection was found to be a health and safety hazard as the resident is a smoker and there were ‘nub ends’ on the carpet and the carpet had a number of burns from cigarettes. The manager stated that there are designated smoking areas provided and residents are requested not to smoke in their rooms, however it was evident that this resident was not adhering to the homes smoking rules. The manager agreed to take this issue up with the resident concerned. There are a more than the required number of bathrooms/showers and toilets provided. There are three communal areas provided all are light warm and clean. There is a Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 15 garden area provided with seating for residents use. The home has wheelchair access throughout. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 16 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): 33.35. Staff training has improved however there is still a lack of specific mental health training provided to staff. EVIDENCE: Staff appeared to work as a team staff were observed communicating with one another and supporting each other. The manager has developed a staff training programme which was examined and staff are attending a number of internal and external training sessions which include all the mandatory and induction training, alcohol and substance abuse and safe handling of medication. The manager stated that they are still trying to obtain specific external mental health training for staff and there is ‘is in house training provided on the basic understanding of mental health. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 17 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): 37.38.40.41.42.43. The manager appears to provide clear leadership to staff and residents her door is open so residents are able to approach the manager at any time. Staff expressed a level of confidence in the managers abilities and competence. EVIDENCE: The manager has achieved her National Vocational Qualification level 4 and her registered manager award. Residents spoken to spoke highly of the manager and other staff members. Residents were observed freely coming into the office top speak to the manager throughout the inspection. There are regular staff and residents meetings held the minutes from theses meetings were examined and clearly indicated that residents are involved in discussions about the day-to-day running of the home. The home has a comprehensive policy and procedures manual available to staff The manual provides policies and procedures for the policies identified in Appendix 3. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 18 The service records for the fire equipment; gas and electric were examined and found to up to date. The Environmental Health and Fire officer inspections had taken place and there were no recommendation made. Water tests had been carried out for the prevention of Legionella as required. Health and safety posters were displayed throughout the home and protective clothing was provided for staff. The home has a comprehensive containment of substances hazardous to health (COSHH) manual available to staff. The last fire drill was carried out on 12/12/05 and there are weekly fire alarm test, which are recorded as required. However as indicated previously in this report under Standard 24 one residents smoking habit did constitute a possible fire hazard. The home has a current insurance certificate displayed in the front entrance. All residents financial transactions are recorded as required the records were examined and found to be satisfactory. Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 19 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 x 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 x 23 x ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 3 3 3 x 3 3 2 3 Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 20 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 YA35 Regulation 18(1)(a) Requirement The registered person must provide ongoing mental health training for all staff. The registered person must ensure that where there is a risk of fire identified action is taken to eliminate the potential danger. This would include the unsafe smoking habits of identified resident/s or staff. Timescale for action 01/04/06 2 YA42 13(4)(c) 23(4)(a) 01/04/06 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 staff should achieve NVQ level 2 by 2005 Hollies (The) DS0000020018.V285969.R01.S.doc Version 5.1 Page 21 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.V285969.R01.S.doc Version 5.1 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. 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