Inspection on 25/01/06 for The Hollies

This inspection was carried out on 25th January 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 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 09/04/09

The Hollies 11/04/07

The Hollies 27/06/06

The Hollies 10/05/05

The Hollies 17/01/05

The Hollies 25/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Hollies 11 St Catharines Road Broxbourne Hertfordshire EN10 7LG Lead Inspector Mrs Judith Kent Unannounced Inspection 25th January 2006 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 DS0000019572.V280625.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 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 DS0000019572.V280625.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Hollies Address 11 St Catharines Road Broxbourne Hertfordshire EN10 7LG 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) 01992 445044 01992 446911 Shawlmist Ltd Mr Ronald Hollywood Ms Linda Phipps Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: The Hollies is a large Tudor-style Grade II listed building that is located in a quiet residential area of Broxbourne. It was converted to its present use as a care home in 1984. It offers residential accommodation to a maximum of twenty-seven elder people and there are bedrooms on each of the three floors, served by a passenger lift. There are local shops, a Post Office, bank and pharmacy nearby. Public transport is available a short distance away and the home is equidistant from the town centres of Hoddesdon and Broxbourne. Accommodation is provided in nineteen single occupancy bedrooms and four double bedrooms. There are two lounges, a dining room and a conservatory that leads on to a mature garden. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place from early morning until after lunch. The inspector spoke with service users, both individually and in groups, as well as one family visitor; there was an examination of some records and discussion with the manager and the deputy manager; and observation of care practice and discussion with some staff members took place. Service users and the visitor spoken with were happy with the care provided – comments included ‘I was made very welcome’, ‘the staff cannot do enough for you’ and that the whole staff group, including the housekeeping and catering staff, is responsive to service users and take an interest in their well-being. The majority of key standards were assessed during the inspection of 10th May 2005 and were found to have been met. Where there is no comment in this report, please refer to the report of that inspection. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be reviewed regularly to ensure that they are still relevant and meeting each person’s individual needs; the reports in care plans should give the reader a clearer picture of each person’s daily life and activities. The registered manager has deferred her application for management training and must now gain an appropriate qualification so as to comply with the Care Homes Regulations. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 6 There were some instances of unsafe practice seen at the inspection which the manager needs to bring to the attention of staff. 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 DS0000019572.V280625.R01.S.doc Version 5.1 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 DS0000019572.V280625.R01.S.doc Version 5.1 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): Standard 3 was assessed at the inspection on 10th May 2005 and was met; Standard 6 is not applicable. EVIDENCE: The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 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&9 Care plans are not reviewed regularly and as a result may not reflect service users’ current needs; many of the daily records in care plans do not give a clear picture of each person’s life in the home. Service users’ medication is managed well and people who choose to are encouraged and assisted to take control of their own medication. EVIDENCE: There are care plans in place for each service user, setting out individual needs and how they are to be met. However, the daily records for each person were in many cases repetitive and brief and did not give a clear picture of their daily life in the home. Both the Skills for Care induction training and National Vocational Qualifications (NVQ) stress the importance of concise and accurate report writing and this is an area that the manager may need to devote time to when developing the home’s training programme for the year. One fairly new service user’s records were looked at and while the care plan was in place there had been no monthly reviews recorded which would indicate whether the home was meeting the person’s needs and expectations and whether the care plan needed to be revised. Several other care plans were The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 10 looked at and monthly reviews were generally erratically completed. The management team agreed that this is an area that needs monitoring. Medication administration and records were looked at at the last inspection and were complying with the standard and the Royal Pharmaceutical Society’s guidance. Since then, one service user who has recently come to live in the home has opted to look after and mange his own medication. A risk assessment has been completed and will be reviewed at appropriate intervals to make sure that safe procedure continues to be followed. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 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 & 15 Meals are nutritious and varied and special diets can be catered for. There are organised and ad hoc activities offered to provide interest and stimulation. EVIDENCE: The inspector arrived early in the morning and found the atmosphere in the home relaxed and cheerful; service users offered their opinions and views freely and without prompting while waiting for breakfast to be served. People said that they were happy in the home and satisfied with the service provided. Comments included that the staff were very welcoming and that they couldn’t do enough for the people who live in the home, although they are given encouragement to maintain as much independence as possible. There had been some comments at the previous inspection by some service users that they felt that there were not enough activities organised for them – no such comments were made on this occasion and the manager confirmed that there are both regular activities are organised and that staff also engage service users in ad hoc sing-songs, table games etc. Menus are varied and nutritious, and although there is no set choice to the main meal of the day, the catering staff are aware of individual likes and dislikes and dietary needs and can always offer an alternative. At least one fresh vegetable is offered every day and the kitchen is able to cater for special diets. Meals are generally taken in the dining room, but service users may choose to have them in their rooms if they prefer. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 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): These standards were assessed and were found to have been met during the inspection on 10th May 2005 EVIDENCE: There have been no complaints or allegations of abuse recorded since the last inspection. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 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, 24 & 26 Service users live in a clean, safe and well-maintained home and can choose how they want their own rooms to look. EVIDENCE: The Hollies is maintained to a good standard by the proprietors, who carry out much of the necessary work themselves. A tour of the premises showed that it was clean and odour-free and that service users’ rooms reflect their personal taste and were in good decorative order. Recommendations made by the Community Fire Officer after a recent visit had been attended to promptly. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 14 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 Service users benefit from a trained, although not fully qualified, staff group. New staff have the necessary security checks completed before they start work in the home, ensuring the protection of service users. EVIDENCE: Although the home has not yet achieved the required 50 of staff qualified to NVQ Level 2, there are six careworkers who hold the certificate and more are currently taking the course. Current level of qualification is 27 , but this will rise towards meeting the standard when these have completed the training. Induction training for new staff is based on the Skills for Care model, which links with the NVQ curriculum; care staff are encouraged to join an NVQ course and spoke positively of the encouragement and support given to them during the training by the management team. There is a programme of in-house training, which has recently included Dementia Care, and mandatory training (moving and handling, food hygiene, first aid) is kept up-to-date. There had been concerns at previous inspections that the necessary checks had not been completed prior to staff starting work in the home; while no new staff had started since the last inspection, the manager was in process of recruiting two people and was awaiting confirmation of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks, indicating that the correct procedure has been observed. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 15 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, 33, 35 & 38 Service users and their families are given the opportunity to comment on the quality of the service and to influence how the home is run. They can be confident that the home takes good care of their financial affairs. Although the home is run competently at present, a management qualification will enable the registered manager to gain skills and knowledge to further benefit both service users and staff members. EVIDENCE: The manager and deputy manager are developing a quality assurance system designed to give them information and feedback about the service the home provides. Service users, relatives and other stakeholders are surveyed regularly, and reviews and audits of in-house procedures and the home environment are carried out and analysed to identify any areas of concern and to develop an action plan to tackle any shortcomings. Both managers said the process is useful and highlights where they may need to take action to ensure that continuous progress is maintained. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 16 The majority of service users’ finances are managed by themselves or their family members, but the home looks after money for one person. This account was looked at during the inspection and found to be well-documented with receipts for purchases attached and a correct balance. The manager does not hold the NVQ in Care and Management at Level 4, or any equivalent, and is urged to do so as soon as possible in order to meet the requirement in Standard 31 and to enhance her knowledge and skills to further the effective management of the home. Neither the manager nor the deputy manager was able to show at this inspection that any other management training courses had been taken up. The Control of Substances Hazardous to Health (COSHH) risk assessments were looked at during the inspection and many were seen to have been in place for several years. It was recommended that they are reviewed to make sure that they are all still relevant and appropriate. Observation of care staff at work showed that there was some unacceptable practice that must be tackled by the mangers; two examples were seen – a wheelchair was being used without the footplates and one person was being helped from her chair by lifting under her arms. Both are unacceptable and staff must be reminded of the need to work safely and in accordance with health and safety guidance and training, both for service users’ and their own benefit. The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 17 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x 3 x 3 STAFFING Standard No Score 27 x 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 18 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 2 3 Standard OP7 OP31 OP38 Regulation 15(2)(b)& (c) 9 13(5) Timescale for action Care plans must be reviewed and 25/01/06 recorded with the service users concerned at least monthly The manager must gain relevant 31/12/06 management qualifications The manager must ensure that 25/01/06 safe working practice is carried out when staff use wheelchairs and help people to mobilise. Requirement 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 3 Refer to Standard OP7 OP38 OP28 Good Practice Recommendations The records in each service user’s file should give a clear picture of their daily life in the home . COSHH risk assessments should be reviewed to ensure that they carry up-to-date information. A minimum of half of the care staff should be qualified to NVQ Level 2 The Hollies DS0000019572.V280625.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 DS0000019572.V280625.R01.S.doc Version 5.1 Page 20 - 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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