Inspection on 03/05/07 for The Hollies

This inspection was carried out on 3rd May 2007.

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 07/09/09

The Hollies 02/10/08

The Hollies 17/01/07

The Hollies 29/11/05

The Hollies 03/06/05

The Hollies 15/12/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Hollies Florida Street Castle Cary Somerset BA7 7AE Lead Inspector Alison Philpott Unannounced Inspection 3rd May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies DS0000061198.V336716.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 DS0000061198.V336716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address Florida Street Castle Cary Somerset BA7 7AE 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) 01963 350709 01963 351396 M & J Care Homes Ltd Mrs Judith Marion Adams Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/01/07 Brief Description of the Service: The Hollies is a residential care home providing care and support for up to 12 older people. The home is in Castle Cary, in a quiet residential road, close to the centre. Local amenities including shops, cafes, a small museum and the post office are close by. The home owners are closely involved in the day to day running of the home. The accommodation is arranged on two floors. There is a stair lift, but no shaft lift. There are two lounges, an attractive dining room/conservatory which overlooks an enclosed and sheltered garden. The home has limited parking space for visitors at the front of the property. The current fee range is £380 to £425 per week. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous inspection took place on 17 January 2007. This unannounced key inspection took place over 6.5 hours. Mrs Judith Adams, Registered Manager was available throughout the inspection. There were thirteen residents living in the home. During the inspection, eight residents, and three members of staff were spoken with. The Inspector viewed the home. Staff were friendly and were observed being kind and caring toward residents. Records viewed included care plans; risk assessments; medication; health and safety records; staff recruitment & training. The Inspector would like to thank the residents and staff for their involvement and participation in the inspection process. As a result of this inspection the home has no requirements and four recommendations. What the service does well: What has improved since the last inspection? The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 6 The receipt of medication on hand transcribed medication administration record sheets is now being signed by two members of staff and dated, to safeguard residents. Grab rails have been tightened as far as possible to minimise any risk to residents. The home has improved the access to the hoist for staff to reduce the risk of injury. Two signatures are being obtained for financial transactions, to ensure that residents monies are safeguarded. Roll calls have been removed from the walls to provide a more homely environment and respect residents’ privacy, dignity and confidentiality. COSHH (Control of substances hazardous to health) data sheets for cleaning products have been obtained to safeguard residents and staff in the event of accidental exposure to chemicals. 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 summary of this inspection report can be made available in other formats on request. The Hollies DS0000061198.V336716.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 DS0000061198.V336716.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes pre-admission assessments for prospective residents to ensure that their needs can be met appropriately. EVIDENCE: The inspector viewed two pre-admission assessments for residents that have recently moved to the home. These contained a good level of detail so that the manager can be sure that the home can meet the needs of the resident. The home has not introduced intermediate care since the previous inspection. The Hollies DS0000061198.V336716.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are person centred and generally provide sufficient information for staff to follow to ensure that residents needs are met appropriately. Medication is stored securely. The home’s procedures safeguard residents. Residents’ privacy and dignity is respected. EVIDENCE: Three care plans were viewed. These contained a good level of detail for staff to follow. They included resident’s individual preferences and promote independence. The more recent care plans contain detailed information for staff to follow in relation to assisting with washing. The home should now The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 10 review existing care plans to ensure all residents specific needs continue to be met appropriately. Risk assessments relating to moving & handling and access to the garden were viewed. Residents are able to access healthcare professionals including GP, District Nurse, Social Worker, Dentist, Chiropodist and Optician. Residents are very happy with the care and support that they receive. All residents spoken with commented on the kindness of the staff. One resident said ‘I feel so well looked after I believe I’ll live to 100” and “the staff are extremely good”. The home’s medication is stored securely. The home has obtained a medication trolley since the previous inspection. The home uses a Monitored Dosage System. The Medication Administration Record Sheets were viewed. These were fully completed. Where sheets had been hand transcribed, two signatures and the date had been recorded. Variable doses had been recorded. The home undertakes a monthly medication audit and any shortfalls are followed up with the staff concerned. The manager advised that the home was not storing any controlled drugs at the time of the inspection. The home has a lockable medication fridge which is in use. The daily temperatures had been recorded to ensure the fridge is storing medication safely. Staff were able to demonstrate how they respect residents privacy and dignity. Staff were observed knocking on bedroom doors before entering. The Hollies DS0000061198.V336716.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a programme of activities. Visitors to the home are made to feel welcome. Residents are very happy with the food at the home. EVIDENCE: The home’s activities programme is displayed on the notice board. Activities include crosswords, sing songs, raffles, games, aromatherapy, reflexology and gentle exercise. During the inspection, residents were observed reading, watching television, chatting and going out. One resident enjoys reading and makes use of the local library. The home also keeps a stock of books for residents. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 12 Resident spoken with described birthday and wedding anniversary celebrations that had been held recently at the home. The home holds Holy Communion once a month for those residents that wish to attend. Residents confirmed that their visitors are made to feel welcome. One relative who was at the home during the inspection confirmed that they were very happy with the care provided. Staff were observed offering choices to residents through the day. Residents confirmed that they spend their day as they wish. The menus were viewed. The home offers home cooked food and fresh vegetables. Some residents choose to have breakfast in their room. Other residents come down to the dining room. Residents have a choice of breakfasts, including a cooked breakfast option. There is also a choice available at teatime. The home currently provides one main meal at lunchtime. If a resident doesn’t want the meal, the home will provide an alternative. The manager advised that they are reviewing the menus to provide a choice at lunchtime. There are also plans to put the menu on display so that resident can see the choices available to them. Residents spoken with confirmed that they are happy with the food at the home. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure is accessible to residents. The home’s policies protect residents from the risk of abuse. EVIDENCE: The home’s complaints procedure is available at the home’s entrance and within the Residents Handbook. Each resident has a copy of the handbook. The home had not received any complaints since the previous inspection. Residents spoken with knew who to speak to if they should have any concerns. The home has policies relating to whistleblowing and abuse. Two staff files were viewed. These contained completed POVA First Checks and completed Criminal Record Bureau checks. The staff did not commence work at the home until the POVA First Check was received. Staff spoken with knew who to speak to if they witnessed abuse. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well maintained and homely environment with comfortable furnishings. The home was clean. The home has systems in place to control the spread of infection. EVIDENCE: The inspector viewed the home. The environment is homely and well maintained. The lounge area is pleasant with lots of natural light and comfortable furnishings. The home has two dining areas. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 15 The home’s garden was well maintained. The borders were well stocked and colourful. The majority of residents bedrooms overlook the garden. Residents spoken with in their rooms appreciated the attractive outlook. The garden area is slightly elevated and access is difficult for some residents. However, the home is reviewing the design of the garden. All areas of the home were clean, tidy and smelt fresh. Gloves and aprons were available to staff. Liquid soap, alcohol gel and paper hand towels were available in toilets and bathrooms. However, two bathrooms and one toilet had fabric towels in situ. These were removed by the manager during the inspection. The home should ensure that fabric towels are not provided in communal areas as this does not control the potential spread of infection. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appeared to have sufficient staff on duty to meet resident’s needs. Staff recruitment procedures are robust and protect residents. The home has a comprehensive staff training programme. EVIDENCE: The rotas were viewed. The home employs two care staff in the morning; two care staff in the afternoon and evening; and one waking care staff at night with on call support from the management team. The home should keep its staffing levels at night under review to ensure that there are sufficient staff on duty in accordance with the levels of dependency of each resident. During the inspection, there appeared to be sufficient staff on duty to meet residents needs. Residents spoken with confirmed that staff are available when they require assistance. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 17 The inspector viewed two staff recruitment files. These contained all of the required documentation listed in Schedule 2 of the Care Homes Regulations 2001. The home has a staff training programme which includes health & safety, food hygiene, fire safety, safe handling of medicines. Practical moving and handling training is planned for 15/05/07. Two members of staff hold a current first aid certificate. The home should ensure that first aid training is provided so that there is at least one first aider on duty at all times. Three members of staff hold an NVQ at level 2 or above. Six members of staff are currently working towards NVQs at level 2 or above. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is developing its quality assurance systems. Residents’ monies are safeguarded. The home promotes the health and safety of residents and staff. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 19 EVIDENCE: Mrs Judith Adams is Registered Manager at the home. The manager has a good support network which includes senior carers. The home is planning to hold a residents meeting and distribute surveys to residents. The last survey was carried out in November 2006. Completed surveys are collated and action plans are written. The home is also looking at distributing surveys to visitors, relatives and other stakeholders. A suggestion book is available in the entrance hall. The home carries out a monthly medication audit. The home stores small amounts of cash for some residents. The monies are stored securely. Two balances were checked and found to be correct. The financial transaction record had been double signed by either a member of staff and the resident or two members of staff if the resident was unable to sign. Receipts had been obtained and filed for purchases. This is good practice as it safeguards the residents monies. Some of the home’s health and safety records were viewed at the previous key inspection on 17th January 2007. The home’s hoist and wheelchairs were being serviced during the inspection. The bath lifts were due to be serviced and the manager confirmed that this is planned. The home’s fire alarm system is tested weekly. Emergency lights are tested monthly. Fire exit doors opened easily and exits were clear. A fire drill was carried out on 23.03.07. The home should record the names of those who attend the fire drill to ensure that all residents and staff take part in a drill, so that they know what to do in the event of a fire. Some areas highlighted as requiring attention by the Fire and Rescue Service are pending prior to building works due to take place. Food in the fridges was covered and dated on opening. Fridge and freezer temperatures are checked and recorded daily The home has obtained COSHH (Control of substances hazardous to health) data sheets for its cleaning products since the previous inspection. This safeguards residents and staff in the event of accidental exposure to chemicals. The home’s employer’s liability certificate was on display and valid until 2nd May 2008. The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 20 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X 3 X X 3 The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The home should review existing care plans and provide detailed guidance for staff to follow in relation to washing to ensure that the resident’s specific needs are met appropriately. The home should ensure that fabric towels are not provided in communal areas as this does not control the potential spread of infection. The home should ensure that first aid training is provided so that there is at least one first aider on duty at all times. The home should record the names of those who attend the fire drill to ensure that all residents and staff take part in a drill, so that they know what to do in the event of a fire. 2. 3. 4. OP26 OP30 OP38 The Hollies DS0000061198.V336716.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000061198.V336716.R01.S.doc Version 5.2 Page 23 - 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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