CARE HOMES FOR OLDER PEOPLE
The Hollies 11 Queen Edith`s Way Cambridge CB1 7PH Lead Inspector
Andy Green Unannounced Inspection 2nd December 2005 13:30 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 DS0000015232.V270693.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 DS0000015232.V270693.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Hollies Address 11 Queen Edith`s Way Cambridge CB1 7PH 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) 01223 245774 01223 414077 Guy Curtis Care Limited Sandra Catherine Margaret Bailey Care Home 25 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (25), Physical disability (1) The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 4 DEE, 4 MDE subject to a maximum total from these 2 client groups combined of not more than six of the total 25 residents and 1 PD. 17th August 2005 Date of last inspection Brief Description of the Service: The Hollies is a residential service for older people over 65. The home provides accommodation for up to 25 service users, some of whom may have dementia care needs. The home is situated in an established residential area on the outskirts of the city of Cambridge. It is within easy reach of the city centre, Addenbrookes hospital and close to good road and rail links. The home provides accommodation on two floors and there is a passenger lift providing access to the first floor. All of the bedrooms are offered as single occupancy with seven having en-suite facilities. There are adequate bathroom facilities. The home offers generous communal space with two separate lounge areas and a dining room. There are attractively maintained gardens to the front and rear of the property. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Regulation Inspector, Andy Green undertook this unannounced inspection on 2nd December 2005. The inspector met with the manager, proprietor, service users and a relative to gather views regarding the services offered in the home. A number of records were inspected including care plans, training records, fire records and staff files. A tour of the premises was also undertaken. What the service does well: 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. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 6 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 DS0000015232.V270693.R01.S.doc Version 5.0 Page 7 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): 1,3,5, Service users have access to good information, and can make an informed choice regarding the home’s services. EVIDENCE: There have not been any further additions to the Statement of Purpose or Service Users Guide since the last inspection. However the manager needs to include her details now that she has become registered with CSCI. The provider also needs to update his details now that he is no longer the registered manager. Each enquiry made to the home regarding a potential admission is logged on a monitoring sheet. The manager stated that the local authority and “Home Finders” are notified of any vacancies that occur in the home to ensure that referrals are received. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 8 The manager and a member of the care team continue to visit prospective service users to carry out a needs assessment as required by this standard. There have been no changes made to the assessment procedure since the last inspection. The manager however, stated that the assessment process is reviewed during the year to ensure it remains effective and provides up to date information. Prospective service users and their family/relatives are encouraged to visit as part of the assessment process, prior to admission to ensure that the prospective service have a chance to experience life in the home. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Service users receive appropriate health and personal care to meet their assessed needs. Medication is administered and recorded accurately. EVIDENCE: The care planning system has been reviewed and new files have been implemented. The information is clearly laid out in a more accessible manner for recording and reviewing care in the home. The manager stated that the new care plan process would be monitored and reviewed to ensure their effectiveness. Two service user files were inspected and they showed sufficient detail to ensure that individual service users assessed needs are being met. There was evidence that reviews are carried out regularly with any changes in care clearly documented. Service users receive visits as required from a variety of healthcare professional including district nurses and a chiropodist. The home’s relationship with local GP surgeries and district nurses ensures that healthcare is regularly monitored and this was clearly evidenced during visits being made during the inspection. Relatives of service users are informed when there are any healthcare changes and a relative spoken to on the day of inspection confirmed
The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 10 this to be the case. Medication administration records were inspected and were found to be recorded accurately. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Staff provide appropriate support to ensure that service users have access to activities appropriate to their needs. EVIDENCE: The home continues to offer variety of activities both in the home and the local community, which are organised throughout the year. These include, musical entertainers, board games, summer fetes and Easter and Christmas events. Relatives visit on a daily basis to take their relative out for lunch and to spend time together in the lounge or gardens. The atmosphere in the home was cheerful and busy and service users were socialising with each other and staff in the lounge. A chair aerobics session was actively being enjoyed by a number of service users in the communal lounge. A monthly newsletter continues to be circulated in the home giving details of forthcoming events in the home. There is a varied range of meals offered throughout the day and service users have a choice of alternatives to the suggested menu choices. Snacks and drinks are also available at all times during the day. Service users spoken to were most complimentary about the services and support that they received and found living in the home a positive and comfortable experience.
The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 12 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): 16,18 The home has a complaints process to make sure that service users have their complaints or concerns listened to and acted upon properly. Service users are protected from abuse. EVIDENCE: The home has a clear complaints procedure, which includes agreed timescales to make sure that all complaints are fully investigated and actioned appropriately. The home has not received any complaints since the last inspection. CSCI has also not received any complaints regarding the home. The home has a satisfactory policy regarding Adult Protection, which is in line with the Local Authority policies. The manager stated that she is going on a three day POVA course and would then cascade training to the staff team on a regular basis to ensure that service users are protected from abuse. Care staff were observed to speak to service users in a friendly and respectful manner. A relative spoken to stated that she found the management and care in the home to be of a consistently high standard and that she was always informed of any events or changes in her relatives care. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 13 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): 19,20,24,26 The environment is suitable for the needs of those living in the home but some improvements are required. EVIDENCE: There is an ongoing maintenance and decoration programme and there are plans to redecorate the majority of the downstairs communal areas in the New Year. The home is kept in a clean and tidy condition and was free from odours. The gardens are well presented and maintained throughout the year with a variety of planted areas. There is seating in the gardens adjacent to the main lounge which service users enjoy using during the warmer months of the year. Service users are encouraged to personalise their rooms and bedrooms that were seen during the inspection individually reflected service user’s style preferences. Service users have the specialist equipment required to maximise their independence and advice from an Occupational Therapist is sought when required. Additional heating has been installed in one of the communal lounges.
The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 14 The kitchen was presented in a hygienic manner but it was noted however that there were areas of flaking paintwork on the ceiling, which need attention. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27,29,30 The home’s recruitment policy and processes makes sure that service users are protected from harm. Training is provided to make sure that care staff are competent to deliver care to the service users they support. EVIDENCE: All staff are issued with job descriptions and clear details of their areas of responsibility. The home has a thorough recruitment procedure including CRB/POVA checks and appropriate references taken up before employment commences. One full time carers’ post is currently being advertised. It was noted that recent photographs have been added to individual staff files. The home’s training files was seen and there was evidence to show that staff members regularly receive a variety of training in health and safety and elderly care issues as part of an ongoing process throughout the year. The manager monitors training and records showed updates to ensure safe working practice are regularly organised including infection control, moving & handling, dementia care and Bereavement. Staff spoken to stated that they received regular training and information including NVQ level courses. The manager is also an NVQ assessor and offers ongoing support to the care staff in the home. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 16 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): 31,32,36,38 The home is well managed and the manager provides supportive leadership and guidance to staff to ensure that service users receive high quality care. EVIDENCE: The manager has worked in the home for a number of years and continues to provide a clear and inclusive style of management. She has recently successfully registered as manager with CSCI and she has also completed an NVQ level 4 in Management & Care. The provider continues to be actively involved on a daily basis and provides ongoing support to the manager. Staff and relatives spoken to during the inspection also confirmed that they were well informed and supported by the management in the home. Recorded supervision sessions are in place for all a staff to make sure that their work and development needs are monitored. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 17 Fire records were seen and although weekly alarm tests are regularly recorded the testing of the emergency lighting system needs improvement as records showed significant gaps. Regular equipment maintenance checks are made and an engineer had recently carried out a check of the passenger lift. The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 18 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 2 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 2 The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 19 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 OP1Op1 Regulation 4 (c) Requirement Timescale for action 31/01/06 2 OP191 3 OP38 The Statement of Purpose needs to be updated to provide the information as required in Schedule 1. 23 (2) (b) The premises need to be kept in 31/12/05 a good state of repair and decoration needs to be carried out to the kitchen ceiling. 23 (4) ( c) Regular testing of the emergency 02/12/05 (v) lighting system must be carried out with appropriate records kept. 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 NA Good Practice Recommendations None The Hollies DS0000015232.V270693.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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