Inspection on 19/12/05 for The Hollies

This inspection was carried out on 19th December 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 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 09/12/08

The Hollies 12/01/07

The Hollies 18/07/05

The Hollies 25/01/05

The Hollies 25/08/04

The Hollies 20/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Hollies 86-90 Darnley Road Gravesend Kent DA11 0SE Lead Inspector Sally Hall Announced Inspection 19th December 2005 10:00 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 DS0000024034.V260681.R01.S.doc Version 5.0 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 DS0000024034.V260681.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Hollies Address 86-90 Darnley Road Gravesend Kent DA11 0SE 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) 01474 568998 01474 332980 evergreenhce@btinternet.com Mr Peter Anthony Rogers Mrs Helen Elizabeth Rogers Mr Peter Anthony Rogers Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2005 Brief Description of the Service: The home is located close to shops and public transport and Gravesend town centre is within walking distance. The Hollies was originally two semi-detached houses, which have been converted into one building and extended. The extension to the home is modern and purpose built, all the rooms within it have en-suite facilities. It is decorated to a high standard and comfortably and attractively furnished. The refurbishment of the rest of the home has also been to a high standard. There are 2 large living rooms and 2 smaller quiet rooms, a separate dining room and a large conservatory. There is a large attractive garden with a patio area and lawn. The home is accessible throughout and has a new shaft lift and handrails fitted in halls and corridors throughout. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced Inspection at The Hollies took place on 18th December 2005 at 10am and was completed by 3.15pm. The Inspector agreed and explained the inspection process with the owners. Documentation and records were read, including care plans. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. A tour of premises was also undertaken although not fully inspected. The focus of the inspection was to assess The Hollies in accordance to the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. What the service does well: What has improved since the last inspection? No requirements or recommendations were identified during the last inspection in July 05. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 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. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 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 DS0000024034.V260681.R01.S.doc Version 5.0 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 the following standard(s): 2-5 All residents receive clear information in a contract/terms and conditions of their stay. Resident’s needs are fully assessed to ensure that the home can meet their needs. Residents are given opportunities to view and sample the care offered before committing themselves to permanent care. EVIDENCE: Pre-assessment documents were seen on the files sampled. All prospective residents are visited prior to admission and the owner and manager undertake an assessment of their needs. The assessment record completed at this time is comprehensive and covers all aspects of the residents’ welfare. Information taken about the resident and their medical history is recorded and used to ascertain if the home will be able to meet their needs. The owner explained that if the referral came via the local authority then they would receive an assessment and care plan from the placing care manager. These were seen on file. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 9 The home is to be commended for its commitment to staff training. The training manager was able to show that all staff receive the required training. A training matrix seen showed that staff are being trained to look after the needs of the residents they currently care for. This training is ongoing and the matrix clearly showed when courses needed to be repeated. The training manager explained that 92 of the care staff at the home have an NVQ level 2 or above. All prospective residents and their families are invited to visit the home prior to admission. At this time they are shown the room that is available and the facilities the home has to offer. If the resident chooses to move into the home this will be on a 28-day trial basis. At the end of this time a review is held to ascertain if the home is meeting the resident’s needs and that the resident is happy. If the trial period has been successful the stay then becomes permanent. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 Residents’ personal, social and health care needs are met according to their needs and wishes. Residents receive a high standard of personal care, are treated with respect and their privacy is respected at all times. EVIDENCE: The home has a very comprehensive assessment process and the care plans seen were also very detailed. From observation and comments from residents during the day, it was evident that staff work hard to fulfil the residents needs. However, daily records did not cross reference well with the care plans. Staff are not fully recording the care and social interaction they have with residents. Gaps between entries were also discussed with the manager and owner. The daily records did not record the times that events and care provision took place. Residents are able to keep their own doctor when possible. New residents can choose between a number of surgeries locally if they are moving from another area. District nurses visit as required. The owner confirmed that the chiropodist visits the home every six weeks and that the optician and dentist all visit the home when required. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 11 The manager explained that only staff trained to do so carry out the administration of medication and they ensure that two staff are on every shift. The medication storage room was inspected. It was tidy, well ordered and clean. Medication was stored correctly. A check of the medication records indicated that staff are giving and recording medication correctly. The Medication Record Sheet did not state if residents have any allergies. The manager was asked to complete this information. Sheets did show that medication is checked in when it arrives at the home. The home has no controlled medication at this time, if it does in the future it will need to correct storage to be installed. During the tour of the building staff were heard addressing residents by their name and were sensitive about any personal issues being discussed. The residents said “the staff treat us with dignity”, “you’re never made to feel anything is too much trouble” and “the staff are easy to talk to about anything”. Staff were seen knocking on bedroom doors before entering residents rooms. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Residents benefit from a range of activities, entertainment and numerous outings on a regular basis. Family and friends are encouraged to visit and the home has a friendly and welcoming atmosphere. Residents benefit from a varied and nutritious menu. EVIDENCE: The home has an activity programme. On the day of inspection a large number of residents were seen enjoying a chat with staff and students. Activities are normally organised by an activity co-ordinator, but a new coordinator has just been taken on who will start after Christmas. In the mean time activities are continuing facilitated by staff. Activities on offer included gardening, bingo, quizzes, craft making and music/sing-a-long. Outings, seasonal activities and outside entertainment are also organised. There is a craft person, and someone who specialises in exercise, which is provided weekly. Residents are able to choose which activities they wish to participate in. Residents spoken to said there were things they can join in with through the week. They particularly liked the lunches out at the pub. The home operates an open visiting policy and residents can meet with their relatives in private in the quiet lounges or their bedroom. A number of friends and family were observed visiting relatives at various times during the day. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 13 One family friend spoken with said that they are always made to feel welcome and enjoy visiting the home. They were very positive about the way the home provides for their friend. It was evident from discussion with several residents that the routines of the home are sufficiently flexible to allow for individual preferences in respect of personal care. Throughout the day residents were seen being encouraged by staff to make choices about various aspects of their lives. Residents said they felt able to choose how they spent their day and the staff help them to do this. Residents have a choice of meals through the day and lighter options are also available. A record of what choices the residents make is kept, and if a resident does not eat well the owner said this is recorded. The choices available on the day of inspection were appetising, but several residents said they did not enjoy the meals provided. The owner and manager have tried to find out why some residents are not happy with the meals and will broach the subject again at the next residents’ meeting. The lunchtime meal was sampled by the inspector and was very tasty. Although the menu did not show a choice, the chef asks each resident every morning what they would like. They are offered a choice of two main meals and if these are not liked the chef will cook what they request. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has a clear complaints procedure and service users and relatives are aware of how to complain. The home has an adult protection policy for the protection of its service users. EVIDENCE: There have been no complaints since the last inspection. Service users spoken with were well aware of their right to complain and generally presented as very satisfied and happy with the service provided. The home has a copy of the local authority adult protection protocols issued earlier this year, which they follow. There is a whistle blowing policy for staff. All staff have undertaken adult protection training. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 26 The home has sufficient bathroom and toilet facilities strategically place for the convenience of the residents. Residents benefit from a clean and well maintained home. EVIDENCE: The home has a number of rooms with en-suite toilet and shower. A few rooms have a toilet en-suite. Bedrooms that do not have these facilities have a toilet nearby that is shared with a maximum of four residents. The home has a sufficient number bathrooms and toilets for the number of residents living at the home. The downstairs bathroom is also a wet room and an assisted shower. The room as been thoughtfully decorated and looks warm and inviting. Domestic staff are to be congratulated on the home’s cleanliness. On a walk around the building there were no offensive odours and all rooms were well presented and very clean. This was true of the staff areas such as the laundry. The red sack system is used in the laundry and the home has a sluice machine to reduce the risk of cross contamination. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 16 The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30 The residents benefit from having staff available in sufficient numbers and with the appropriate skills to meet their needs. Residents also benefit from having trained staff caring for them. EVIDENCE: The staff rota seen showed that the home rotas more staff than indicated by the staff forum. This investment in staff means that they have time to encourage residents to do what they can for themselves and have time to sit and chat during the day. Staff spoken to said that because they are not rushed and are happy this helps the residents to feel relaxed and happy. Residents asked all said that there are always staff around to help them when they need it. The training commitment of this home is to be commended, see standard 4 above. Staff spoken to all said that they feel supported and have found the training helpful in their work with the residents. This home also invests highly in its domestic and ancillary staff, and this has promoted the team spirit within the home. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36, 38 Residents benefit from the warm and inclusive atmosphere within the home. The home strives to ensure that the health, safety and welfare of the residents is promoted and protected. Residents benefit from staff who receive regular formal supervision. EVIDENCE: The home has a warm and friendly atmosphere. Good interaction was observed between the residents, staff, manager and the owners. Residents spoken to said that they felt comfortable asking staff for help and expressing concern if they were not happy. The staff said that they feel supported and enjoy being part of a team. The home has the facility to hold a small amount of personal money for residents who would rather not look after money themselves. A check of the The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 19 money and corresponding records showed very small discrepancies. On examination it was felt that this was more to do with the system being used. In each case the balance showed more money was available than was shown. The system being used is to be reviewed. The supervision notes seen for formal supervision showed that this is not happening six times per year. However it is happening every 3 months and the process involves input from the owners, manager and training manager who takes the supervision. Supervision is a two way process, and staff are given dates in advance. The training manager comes to the home at night to supervise the night staff and the domestic and ancillary staff also receive supervision. Regular staff meetings are also held. The fire test record book evidenced that tests were being carried out in the home as required. The compliance certificates for LOLER for the lift and bath hoist was seen. Certificates were seen for the electrical installation, electrical appliances, fire alarm system, boilers, emergency lighting, call alarm system. The training matrix seen showed staff had undertaken the required courses, such as manual handing, infection control, fire training health and safety etc. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 20 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 X 3 3 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X 3 X X X 4 STAFFING Standard No Score 27 4 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 2 X 3 X 3 The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 21 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. 1 Standard OP35 Regulation 20 Requirement The registered person ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. The system for recording the service users monies must be reviewed. Timescale for action 31/01/06 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 OP7 Good Practice Recommendations Staff should record more information about the care provision and the interaction they have with service user during the day. Times of events and care provision should also be recorded and no gaps left between entries. The Hollies DS0000024034.V260681.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000024034.V260681.R01.S.doc Version 5.0 Page 23 - 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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