Inspection on 27/01/06 for The Hollies

This inspection was carried out on 27th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Hollies 05/11/08

The Hollies 16/11/06

The Hollies 13/07/05

The Hollies 20/01/05

The Hollies 06/07/04

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

CARE HOMES FOR OLDER PEOPLE The Hollies 27 Church Lane Garforth Leeds West Yorkshire LS25 1NW Lead Inspector Paul Newman Unannounced Inspection 27th January 2006 11:45 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 DS0000001462.V280311.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 DS0000001462.V280311.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Hollies Address 27 Church Lane Garforth Leeds West Yorkshire LS25 1NW 0113 287 1808 0113 2875591 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) Garforth Residential Homes Limited Mrs Nicola Berry Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: The Hollies is a care home owned by Garforth Residential Homes Limited and is situated in Garforth, a suberb of Leeds. The home provides personal care and support to twenty-eight older people. Nursing care is not provided but the home is supported by local healthcare services. The property is an Edwardian building, with a recent extension and all rooms are single occupancy. The grounds include car parking facilities, and shrubs to the perimeters of the grounds. The companys sister home, St. Armands Court is situated across the courtyard. The home has a passenger lift and communal facilities include a conservatory, three lounges and a dining room. The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 13 July 2005. There have been no further inspections until this unannounced visit but there was one meeting on 25 October 2005 to discuss proposals to change the registration categories for the home. The people who live in the home prefer the term resident, and this is the term that will be used throughout this report. The purpose of this inspection was to gain an overview of the care, services and facilities provided and also to assess progress in the way the home is dealing with issues that were raised in the last inspection report. In addition the inspection took account of proposals to introduce dementia care as new category for its registration with the Commission. During the inspection records were looked at, some parts of the home were seen, such as bedrooms, lounges and bathrooms; care staff were seen carrying out their work; conversations were held with the manager, three other members of staff and six residents. Survey cards were left at the home for residents, relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). These cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of those who replied. The inspection started at 11:45 and lasted for two and a half hours. Not all National Minimum Standards were inspected during this visit, but over the two inspections all core standards have been inspected at least once. To gain a full picture of how the home meets standards, this report should be read in conjunction with previous reports. What the service does well: There is nothing to add to the comments made in the last inspection report and the same comments apply. The home continues to be consistently well managed, with a clear approach to the care of residents whose quality of life and best interests are the main concern of the manager and staff. The staff are well organised. They are experienced, well trained, know what they are doing and have a good knowledge of the residents they care for. They have The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 6 good relationships with residents and relatives. Residents and relatives appreciate the staff and are confident in them. Residents’ rooms are personalised with their own belongings and they exercise choice about spending time in their bedroom or in communal areas. Varied menus provide choice and residents say that the food is good. 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 DS0000001462.V280311.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 DS0000001462.V280311.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): 1 and 3. Standard 6 does not apply to this home. The written information about the home that is given to people thinking about living there is accurate and up to date. Residents’ needs continue to be properly assessed before they move into the home. Well informed and knowledgeable staff meet these needs. EVIDENCE: The proposals to introduce dementia care to the home have been formalised and a formal application has been made. At the time of writing this report, the proposals have now been approved and the home is able to care for fourteen people with dementia. As part of this process the home was required to submit a new statement of purpose that reflected these changes and new approach. The written information accurately reflects the care and services provided at the home. Two care plans were checked. A detailed pre-admission assessment for each of the residents was on file and the information was accurately used to form the basis of a care plan. The staff spoken with had a good knowledge of the The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 9 residents care needs and their personal preferences. Residents said that the staff are very caring. The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 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 and 10. Care plans provide staff with clear, and up to date information and guidance to follow. Staff are aware of residents’ needs and treat residents with dignity and respect. EVIDENCE: Two care plans were checked. Records were detailed, gave clear instructions and guidance to staff, and were up to date with regular monthly reviews. The plans were person centred and identified personal preferences and preferred lifestyles. Medical needs were clearly identified and daily record keeping showed treatment or support from other healthcare professionals. Risk assessments were clear, reviewed regularly and up to date. With the planned introduction of dementia care to the home, the manager has reviewed the care plan documentation and staff training is taking place to make sure that new documentation is effectively recorded and used. This will be checked at the next inspection. Residents said that staff gave them good support, assistance when they needed it and respected their privacy giving the example of knocking on The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 11 bedroom doors before entering. Observations throughout the visit showed staff to be professional but personable with residents and relatives. The relationships were warm and friendly. Residents looked well cared for. Staff were observed to manage the residents sensitively. The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 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, 13 and 14. Residents are encouraged to join in social and leisure activities. Family, friends and visitors are welcomed at the home. EVIDENCE: Each of these four core standards was inspected in detail at the last inspection and met requirements. This inspection checked on any updates or changes. The manager is developing the recording of resident’s life and social history as part of the care planning process. This is an effort to introduce more individually targeted activities for individuals. Since the last inspection children from a local nursery have visited the home, bringing in pictures they have done for residents and singing some songs at harvest festival time. This was much enjoyed and appreciated by the residents. Although no relatives were seen on this occasion, the residents spoken with talked about their family coming in to see them and the manager confirmed that visitors are welcome at any time. This is also made clear in the written information about the home. The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 13 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 not inspected but met requirements at the last inspection. EVIDENCE: The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 14 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): The home is safe and well maintained and offers comfortable communal lounge areas. Bedrooms suit personal needs, can be personalised with your own possessions and made private. The home has aids that make things like bathing and toileting easier. EVIDENCE: All the communal areas and some bedrooms were seen. The bedrooms were personalised with residents’ personal belongings to make them more homely. No health and safety hazards were noted and staff were seen doing their work properly dressed and equipped, and their practices make sure the home is clean, free from unpleasant smells and hygienic. A dispute with the Local Authority about money owed was settled prior to the home taking the matter to Court. This means that the home is now in a position to address outstanding issues raised in previous inspection reports that refer to the decorative order of the home, corridor carpets and radiator covers. This work will be carried out during the spring and summer. Other The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 15 improvements that are planned include the removal of three baths that are not used and replacing these with showers so that residents have a choice. Also planned is a bedroom alteration to create en-suite facilities. The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 16 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, 28, 29 and 30. There is a good core of experienced and well trained staff who know what they are doing. Recruitment policies and procedures make sure that staff are properly selected and vetted before they start work. EVIDENCE: The staff spoken with were confident and had a good knowledge of the residents they care for. Since the last inspection there has been one member of staff that resigned and one appointed. There is a core of established and experienced staff who have worked at the home for a considerable time. Staff talked about training that they had been involved with and this covered key areas of safe working practice and National Vocational Qualifications (NVQ’s). With the planned changes that will introduce dementia care to the home, this has been the focus of more specialised training. The company continues to employ a training coordinator whose role is to make sure that staff training is up to date and in line with the National Minimum Standards. There are well established systems of staff meetings and shift handovers that make sure that up to date information is passed on. Additional staff will be appointed and staffing levels increased in line with Department of Health guidelines as people with dementia are admitted to the home. The personnel files for three newly appointed staff were checked and found to have all the required documentation. This shows that proper recruitment procedures are followed that make sure staff are properly checked and vetted before they take up appointment. The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 17 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 and 35. There is an open and friendly atmosphere created by good leadership and management. There is a clear approach to resident care that is person centred and puts the best interests of individual residents central to staff practice. Residents’ financial interests are safeguarded. EVIDENCE: Since the last inspection, the manager has started the Certificate in Dementia Care. It is clear that she is finding the qualification interesting and challenging and it is equipping her well for the future development of the home. The manager continues to be ‘hands on’ to make sure there is personal ‘on the job supervision’ and checking, as well as the established formal supervision system for the staff team. The staff and residents appreciate her management style. The home conducts an annual satisfaction survey that involves questionnaire surveys being sent to residents, relatives, staff and professional The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 18 visitors. The last survey results were formulated into a report and an action plan made for any improvements that were identified. The atmosphere in the home was warm and good humoured. Staff were busy and their relationships with the residents were good. Lockable facilities are provided in each bedroom so that individuals can keep cash and valuables. The home does not become involved in residents’ personal finances preferring this to be done personally by the residents, or by a relative or other representative like a solicitor. Any additional services that are received like hairdressing are invoiced monthly or paid for personally by the resident. The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X The Hollies DS0000001462.V280311.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 13 Requirement The manager must ensure the home is in good decorative order and corridor carpets replaced. Timescale for action 01/08/06 2. OP25 23 Outstanding from report of 20/01/05 All central heating radiators must 01/08/06 be low surface temperature or fitted with guards. Outstanding from report of 20/01/05 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 OP31 Good Practice Recommendations The manager is commended and encouraged to complete qualifications in the care of people with dementia as part of her personal development and preparation for the possibility of changes in the registration category of the home. DS0000001462.V280311.R01.S.doc Version 5.1 Page 21 The Hollies Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000001462.V280311.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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