Inspection on 22/09/05 for The Hollies

This inspection was carried out on 22nd September 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 14/02/07

The Hollies 10/01/06

The Hollies 03/02/05

The Hollies 17/09/04

The Hollies 11/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Hollies 1 Tremodrett Road Roche St Austell Cornwall PL26 8JA Lead Inspector Alan Pitts Unannounced Inspection 22nd September 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 DS0000009041.V253335.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 DS0000009041.V253335.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Hollies Address 1 Tremodrett Road Roche St Austell Cornwall PL26 8JA 01726 890247 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) Mr Peter Dye Mrs Maryel Dye Mrs Linda Jones Care Home 20 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (20) The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include one named person out of age category Service users to include up to 20 adults of old age (OP) Total number of service users not to exceed a maximum of 20 Service users to include up to 10 adults aged over 65 with a mental disorder (MD{E}) Service users to include up to 10 adults aged over 65 with dementia (DE{E}) 3rd February 2005 Date of last inspection Brief Description of the Service: The Hollies is a period property situated in the heart of the village of Roche. The home provides residential care for up to 20 elderly people, including up to ten that have dementia (DE (E) or a Mental Disorder (MD (E). There is a garden and car parking space to the front of the home, with a lawn and patio easily accessed by service users. A conservatory has been built onto the front of the home, which also provides staff with a new office. Accommodation is provided on two floors accessed by a stair lift. There is a large lounge for non-smokers with an adjacent smaller lounge for those wishing to smoke. Meals are prepared in a spacious kitchen and served in the dining room, this adjoins the lounge. Assisted bathing facilities are provided and all rooms have call bells. Suitably qualified care staff provide personal care within a relaxed, friendly atmosphere. The Registered Providers are committed to training their staff and over 50 have achieved the NVQ level 2 or above in Care. The General Practitioner’s surgery is close by and the home maintains a very good rapport with the local Doctors, the District Nurses and Community Psychiatric Nurses. There are opportunities for service users to socialise and visitors are actively encouraged. The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 22nd September 2005, between 09.00 and 14.00 hours. The inspector met with the Registered Provider, the Registered Manager, the assistant manager, service users and a visiting health professional. The Hollies is a well managed home that benefits from an established and stable staff team. The home has a proactive approach to the welfare and best interests of service users. Overall, the inspector left with a good impression of this home and the care provided to service users. What the service does well: What has improved since the last inspection? The home has obtained a new accident book, which complies with data protection legislation. A new conservatory, which affords increased communal space and a staff office, has been completed. This was the inspector’s first visit to this home. The Hollies DS0000009041.V253335.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 DS0000009041.V253335.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 DS0000009041.V253335.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, 3, 6 Service user have the information they need and their care needs are properly assessed. EVIDENCE: Each service user receives a Statement of Terms and Conditions that includes a breakdown of fees and identifies the room provided. The care documentation for the most recent admission to the home showed that a full care needs assessment took place prior to admission. The home does not provide intermediate care. The Hollies DS0000009041.V253335.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): 8, 9, 10 Service users confirmed they are treated with respect and were complimentary about the kindness of the staff. Medicines are stored and administered appropriately. EVIDENCE: The care documentation shows that service users have access to other health care providers as necessary (e.g. District Nurse’s). All the staff have undertaken ‘Safe Handling of Medicines’ training. The Medicine Administration Records were seen to be in good order. The home has an agreement with their supplying pharmacist who inspects the medicines at least annually. A medication policy is in place. Service user prescription sheets are kept. Service users were observed to be treated with respect and dignity at all times by staff. Staff were seen to knock on doors prior to entering. Service users had access to a telephone in the hall and could have a telephone line installed in their room on request. Visitors were welcome at any time and could be received in private. Mobile screens are provided in the one double room. The Registered Provider should consider providing a ceiling-to-floor screen in the shared room, along with a bedside light for each service user. The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 10 A visiting District Nurse was complimentary about the care provided at The Hollies. The Hollies DS0000009041.V253335.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): 15 Service users receive a well-presented diet, and alternatives are available. EVIDENCE: The home operates a 5-week menu, which displays the constituent for the meal rather than the meal itself (e.g. mince, which may end up as Shepherds Pie or Chile Con Carne). The actual meal provided is recorded. Alternatives are available and are recorded. Vegetables are bought daily from a local shop. The kitchen was seen to be clean and orderly, and of a good size. The following times are approximate: Breakfast: 08.30 Lunch: 12.15-12.30 Tea: 17.15 Supper: 19.00Hot drinks and snacks are always available. The Hollies DS0000009041.V253335.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, 17, 18 The home has a proactive approach to the welfare and best interests of service users. Service users receive the information they need and their legal rights are protected. Service users are protected from abuse. EVIDENCE: A complaints procedure is in place along with the means to record complaints. No complaints have been received by the home or the Commission for Social Care Inspection. Service Users are able to make their own choices regarding participating in the civic process. Information about advocacy agencies has been made available in the Service User Guide for Service Users. Service Users are assisted to vote by the use of postal voting. Service User legal rights are protected. There are up to date documents relating to the Protection of Vulnerable Adults. There is a Whistle-blowing Policy and a copy of ‘No Secrets’. The local procedure is included, and states that all abuse will be dealt with under these procedures. There is an up to date policy on the Safekeeping of Residents Money and Valuables. The Registered Manager should review and amend the Protection Of Vulnerable Adults procedure to ensure that it provides clear instruction to staff, and the necessary contact details, as to the steps to take in the event of an allegation of abuse. The Hollies DS0000009041.V253335.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, 21, 23, 26 The home provides safe, comfortable accommodation that is personalised, wherever possible, to reflect individual service user preferences. EVIDENCE: The layout and location of the home is suitable for its stated purpose. There are in places some steps to negotiate, but access is generally good, aided by good size corridors. There is a stair lift to assist with access between floors. Measurements were not taken, but there appears to be sufficient communal space, which has recently been increased with the provision of a conservatory. Service user bedrooms were seen to be comfortable and personalised to varying degrees. There are sufficient toilets and bathing facilities provided, though currently one bathroom is not used. The Registered Provider should consider; converting the toilet opposite room 12 to a walk-in-shower room; converting the unused bathroom on the same floor to a laundry room; converting the existing small laundry area for additional storage. The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 14 The home was seen to be clean throughout on the day of the inspection. The Registered Provider should replace the existing domestic-type washing machines with an industrial-type machine (with a sluice facility). The Registered Manager should audit the existing staff hand-washing provision and ensure that there is a facility for staff to wash their hands in all communal bathrooms and toilets (e.g. alcohol solution). The Hollies DS0000009041.V253335.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): 28, 29, 30 A skilled and committed staff meets Service user needs. EVIDENCE: The home demonstrates an admirable commitment to staff training overall. There is 18 care staff (not including the Registered Manager) of which 11 have achieved NVQ Level 2 or above, and a further 4 are undertaking NVQ training. Two staff files were inspected. The Registered Manager must review the home’s application form to ensure that it states the job being applied for, and asks for the applicant’s employment history. The Registered Manager must ensure that a reference is sought from an applicant’s last employer, where possible. The Registered Manager should keep a record of interview. An induction programme is in place for new staff, but the registered manager must implement an induction programme that complies with the National Training Organisation (www.topss-england.net - now called ‘Skills For Care’). The registered manager should ensure that all staff have a copy of the General Social Care Council Handbook (www.gscc.org.uk). The Hollies DS0000009041.V253335.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): 32, 33, 34, 35, 36, 37 The Hollies is a well managed home that benefits from an established and stable staff team. The home is run in the best interests of the service users. EVIDENCE: The Registered Manager communicates a clear sense of direction, and the processes of managing and running the home are open and transparent. A quality assurance system is in place. The Registered Manager should expand the quality assurance system to include staff and visiting health professionals, ensure that quality assurance feedback is sought annually, and publish a summary of the findings in the Service User Guide. The Registered Provider has provided written evidence of financial viability, and agreed to continue to do so on an annual basis. The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 17 Service user records are stored securely. Receipts support financial records. The Registered Provider is appointee for two service users. With the exception of specific comments in relation to the National Training Organisation, the home shows a commitment to staff training, including ‘inhouse’ training provided by visiting health care professionals. A staff supervision record is kept, and the Registered Manager agreed to include dates for forthcoming supervision sessions that would be initialled once they have occurred. The Hollies DS0000009041.V253335.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 2 X 3 3 X 2 STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 3 3 2 3 X The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 19 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 29 Regulation 18 Requirement The Registered Manager must review the home’s application form to ensure that it states the job being applied for, and asks for the applicant’s employment history. The Registered Manager must ensure that a reference is sought from an applicant’s last employer, where possible. An induction programme is in place for new staff, but the registered manager must implement an induction programme that complies with the National Training Organisation (www.topssengland.net - now called ‘Skills For Care’). The registered manager should ensure that all staff have a copy of the General Social Care Council Handbook (www.gscc.org.uk). Timescale for action 01/11/05 2 30 18 01/11/05 The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 20 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 2 Refer to Standard 10 18 Good Practice Recommendations The Registered Provider should consider providing a ceiling-to-floor screen in the shared room, along with a bedside light for each service user. The Registered Manager should review and amend the Protection Of Vulnerable Adults procedure to ensure that it provides clear instruction to staff, and the necessary contact details, as to the steps to take in the event of an allegation of abuse. The Registered Provider should consider; converting the toilet opposite room 12 to a walk-in-shower room; converting the unused bathroom on the same floor to a laundry room; converting the existing small laundry area for additional storage. The Registered Provider should replace the existing domestic-type washing machines with an industrial-type machine (with a sluice facility). The Registered Manager should audit the existing staff hand-washing provision and ensure that there is a facility for staff to wash their hands in all communal bathrooms and toilets (e.g. alcohol solution). The Registered Manager should keep a record of interview. The Registered Manager should expand the quality assurance system to include staff and visiting health professionals, ensure that quality assurance feedback is sought annually, and publish a summary of the findings in the Service User Guide. 3 21 4 26 5 6 29 33 The Hollies DS0000009041.V253335.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 DS0000009041.V253335.R01.S.doc Version 5.0 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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