Inspection on 27/06/06 for The Hollies

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 09/04/09

The Hollies 11/04/07

The Hollies 25/01/06

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 Bijayraj Ramkhelawon Key Unannounced Inspection 27th June 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.V301503.R01.S.doc Version 5.2 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.V301503.R01.S.doc Version 5.2 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.V301503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 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. Current fees were quoted as between £ 390 - £ 488 The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from early morning until after lunch. The inspectors spoke with service users, individually and in groups, as well as family visitors; there was an examination of some records and discussion with the manager; and observation of care practices and discussion with some staff members took place. Service users and the visitors spoken with were happy with the care provided and comments included ‘The Hollies’ is a ‘safe haven’ to live in, ‘I was made very welcome’, ‘the staff and food is good’ and that the ‘services they provide are good’. However, there were areas identified in this report which must be improved to ensure that the National Minimum Standards were met. 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 reflect the changing needs of service users and that these should give a clearer picture of each person’s daily life and activities. An appropriate metal medicine cabinet must be provided and a record of the temperature where medicines are stored must be kept to ensure that sub standard medicines are not administered to service users. A choice in the main menu should be provided to ensure that services users are able to choose from the choices offered according to their preferences. Training in the protection of The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 Page 6 vulnerable adults must be provided for all staff to ensure that in the event they are aware of the procedure to follow. Paper hand towels and liquid soap must be provided in all bathrooms and toilets in order to control the spread of infection. The carpet tiles in the conservatory that were very loose must be made safe so that service users and staff are not put at risk of falling and injuring themselves. The bath hot water temperature was 59˚C and rising. This must be reduced to the safe required level of 43˚C in order that service users are not put at risk of being scalded. The COSHH risk assessments should be reviewed to provide up-to-date information and fire drill records should indicate timescales for evacuation as part of the fire safety regulations. 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. 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.V301503.R01.S.doc Version 5.2 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.V301503.R01.S.doc Version 5.2 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): 3 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Adequate information was available to prospective service users so that they can make a decision about the home. There was a thorough admission process in place. EVIDENCE: Adequate information was available to prospective service users and their relatives so that they could make an informed decision about the home. Care plans examined included an assessment of needs for each service user. Reports from other professionals formed part of the care plans. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 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 to 10 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. Good care practices and interactions between staff and service users were observed. However, care plans must be reviewed on a regular basis to reflect the changing needs of service users and must give a clear picture of their daily life in the home. Records of the temperature where medicines are stored must be kept to ensure that substandard medicines are not administered to service users. An appropriate metal medicine cabinet should be provided in accordance with the guidance of the ‘Royal Pharmaceutical Society’. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 Page 10 EVIDENCE: Service users spoken to confirmed that they were well cared for and their individual needs were being met. Good care practices and interactions between staff and service users were observed. All service users were appropriately dressed, well groomed and they confirmed that staff addressed them by their preferred names. Care plans examined included the healthcare and personal needs of the respective service users. However, these were not reviewed on a regular basis, did not reflect the service users changing needs and did not give a clear picture of their daily life in the home. The daily records for each person were in many cases repetitive and brief and did not give a full account of their daily activities. Both the Skills for Care induction training and National Vocational Qualifications (NVQ) stress the importance of concise and accurate report writing. The ordering, administration and disposal of medicines were kept in good order. However, there were no records of the temperature where medicines were stored including the wooden cupboard and the fridge. It was noted that an appropriate metal cabinet was not provided for storage of medicines. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 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 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Service users confirmed that they were given the opportunity to participate in all aspects of daily living. There were organised and ad hoc activities offered to provide interest and stimulation. Autonomy and choice were being promoted. Meals were varied and special diets catered for. However, a choice in the main menu should be provided so that service users are able to make a choice according to their preferences. EVIDENCE: Service users spoken to offered their opinions and views freely and without prompting. They said that the lifestyle in the home matched their expectation and preferences. They felt that they were well cared for and other positive comments were made in relation to the food, activities, staff and the homely atmosphere at ‘The Hollies’. Overall, service users said that they were happy in the home and satisfied with the service provision. Menus were varied and nutritious, and although there was no set choices to the main meal of the day, the catering staff were aware of individual likes and dislikes and dietary needs and offered an alternative when requested. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 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 quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. There was a complaints procedure that all service users can access, both formally and informally. However, all staff must have the appropriate training to ensure that service users are protected from abuse. EVIDENCE: A copy of the complaints procedure was available to prospective and current service users. Those spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. One complaint was received by the home since the last inspection and this was dealt with to the satisfaction of the complainant with records kept. However, staff have not received training in the protection of vulnerable adults as yet. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 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 & 26 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. The home was kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. However, paper hand towels and liquid soap must be provided in the bathrooms and toilets so as to control the spread of infection. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home and its surroundings offered a pleasant and comfortable environment to its service users. These were kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. Service users spoken to said that they were happy with their bedrooms and other facilities. The home has adequate number of domestic staff and records showed that staff have been provided with training in hygiene and infection control. However, the top floor bathroom and the middle floor toilet did not have hand washing liquid soap nor hand paper towels. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 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 to 30 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. 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: There was adequate number of staff rostered on duty per shift during the day and night. Staff files examined had all the relevant documents required by this Standard. Staff spoken to confirmed that they have received appropriate training, this included statutory training. They also said that they receive regular supervision and an annual appraisal and they have been given a copy of the General Social Care Council Code of Conduct. Currently, 4 staff have completed their NVQ Level2, 3 are undertaking this qualification and a further 3 have just started. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 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): 31,33,35 and 38 The quality outcome in this area is poor. This judgement has been made using all available evidence including a visit to this service. There were policies and procedures in place to ensure that service users’ rights were protected. There was an enthusiastic, dedicated and caring staff team who took great pride in the service provision. Staff received regular planned supervision. However, a management qualification will enable the registered manager to gain skills and knowledge to further benefit both service users and staff members. Fire drills records should indicate timescales for evacuation as part of the Fire Safety regulations. The carpet tiles in the conservatory which were very loose must be made safe and the bath hot water temperature which was well beyond the safe required level must be reduced so that so that service users and staff are not put at risk. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 Page 17 EVIDENCE: Staff confirmed that the registered manager operated an open door policy to staff, service users and to their representatives. Good professional interaction between staff and service users was observed. Staff confirmed that they had undertaken all the mandatory training. Service users, relatives and other stakeholders were surveyed regularly, and reviews and audits of in-house procedures and the home environment were carried out. All service users’ managed their own finances or by their family members, except for one whose account was looked at 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. The Control of Substances Hazardous to Health (COSHH) risk assessments were not reviewed to make sure that these were still relevant and appropriate. It was noted that the bath hot water temperature in the top floor bathroom was 59˚C and rising. This must be reduced to the safe required level of 43˚C. A number of carpet tiles near the exit door in the conservatory were very loose and unsafe. Fire drills records did not indicate timescales for evacuation. All statutory records were available for inspection and maintained in accordance with legislation. Staff spoken to were aware that service users can access their records and information held about them in accordance with the Data Protection Act 1998. A valid insurance certificate was displayed and this offered cover of no less than £5 million. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X x 2 STAFFING Standard No Score 27 3 28 3 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 1 The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 Page 19 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 OP7 Regulation 15(2)(b)& (c) Timescale for action Care plans must be reviewed and 25/08/06 recorded with the service users concerned at least monthly. (This requirement is outstanding since the last inspection of 25/01/06). The care plan must 25/08/06 comprehensively reflect the identified needs of the service users. a) Records of the 25/08/06 temperature of the medicines cupboard must be kept. b) Temperature record of the fridge for medicines must be kept. Training in the protection of 29/09/06 vulnerable adults must be provided for all staff. Paper hand towels and liquid 25/08/06 soap must be provided in the top floor bathroom and the middle floor toilet. The manager must gain relevant 31/12/06 management qualifications (This requirement was made in the last inspection of 25/01/06). Carpet tiles in the conservatory 25/08/06 DS0000019572.V301503.R01.S.doc Version 5.2 Page 20 Requirement 2. OP7 15(1) 3. OP9 13 (2) 4. 5. OP18 OP26 13 (6) 13 (3) 6. OP31 9 7. OP38 13 (4) (c) The Hollies 8. OP38 13 (4) (c) were very loose. These must be made safe. The bath hot water temperature was 59˚C and rising. This must be reduced to the safe required level of 43˚C. 27/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP7 OP9 OP15 OP38 OP38 Good Practice Recommendations The records in each service user’s file should give a clear picture of their daily life in the home. An appropriate metal cabinet should be provided for storage of medicines. A choice in the main menu should be provided. COSHH risk assessments should be reviewed to provide up-to-date information. Fire drill records should indicate timescales for evacuation. The Hollies DS0000019572.V301503.R01.S.doc Version 5.2 Page 21 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.V301503.R01.S.doc Version 5.2 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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