Inspection on 31/05/06 for The Hollies

This inspection was carried out on 31st May 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 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 08/07/08

The Hollies 02/08/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Hollies 19/23 London Rd Retford Nottingham DN22 6AT Lead Inspector Stephen Benson Unannounced Inspection 31st May 2006 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 DS0000066387.V293408.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 DS0000066387.V293408.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 19/23 London Rd Retford Nottingham DN22 6AT 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) 01777 707750 RKL Care Ltd Mrs Karen Allen Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category OP Date of last inspection 14/09/05 Brief Description of the Service: The Hollies is a care home providing personal care and accommodation for 22 older people. The home provides short and long term care and will consider emergency admissions.. The home is owned by RKL Care Limited, which is run as a family business. The home is located in Retford close to shops, pubs, the post office and other amenities. The home was opened in 1985 and consists of 3 converted domestic dwellings. The home was purchased by the current provider in Feburary 2006. 14 of the home’s bedrooms are single, and 1 of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors and there is a passenger lift. The home has a well-tended front garden which is easily accessible and a car park to the rear is available for 8 cars The manager said on 31/05/06 that the fees for the service range from £277 £319 per week depending on dependency needs. There are additional charges for hairdressing and chiropody The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2006 by The Commission for Social Care Inspection. The inspection lasted for 4 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, the provider, staff on duty and care practices were observed. Visiting health professionals were spoken with. The premises were not inspected in detail but various areas of the home were visited as part of the inspection What the service does well: What has improved since the last inspection? Staff have been provided with training on completing and using he home’s care planning system. Staff felt that this has been very beneficial. Residents needs are now clearly documented and staff can refer to how these should be met. Residents are having routine health checks including optical and dental. These checks promote the well being of residents Medicine Administration records are fully completed and the home now has a controlled drugs register. As a result the home now has safer practices for residents when administering their medication. The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Hollies DS0000066387.V293408.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 DS0000066387.V293408.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New residents are assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service. EVIDENCE: The manager said that all new residents are assessed prior to admission, normally by Social Services, and a copy of this assessment is obtained prior to admission. An update of the assessment held for users of the respite service is obtained before they move into the home. Staff said that the manager informs them of any new resident coming to the home. Copies of community care assessments were seen on residents’ files. A resident using the respite service said that her normal placement had not been available and was asked if she would like to go to the Hollies. The resident said that she had been happy to come as had spent time at the home previously. There is no arrangement made for the home to provide an intermediate care service. The Hollies DS0000066387.V293408.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, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Permanent residents health, personal and social care needs are set out in an individual plan of care but respite residents are not. Residents health care needs are fully met. Residents require greater protection from the homes procedures for dealing with medicines. Residents feel they are treated with respect and their right to privacy upheld. EVIDENCE: There was a requirement set at the previous inspection concerning the completion of care plans. The new provider arranged for staff to receive training on these and there is considerable improvement in how these are now completed. Staff said they now felt confident in completing and using the plans. At present care plans are not completed for residents using the respite service and these must be prepared. The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 10 Care plans detailed routine health care appointments and residents recounted recent appointments. District nurses spoke highly of the healthcare within the home saying that regimes are always carried out and residents prepared for their visits. One resident said that he was waiting for a hearing aid and another that she wanted her ears syringing. Only senior staff give out medication and Medicine Administration Records were fully completed. Some directions had been copied out by staff and where these have not been prepared by the pharmacist and have been written by a member of staff these should be signed by the person doing so and checked by another member of staff, who also signs to confirm these are correct. Photographs must be provided to the Medicine Administration Records to aid identification. One resident had not wanted to take her tablets when given them and these were left for her to take later. Medication must not be left unobserved. Insulin was seen stored in the kitchen fridge, which the manager said this will be stored in an alternative fridge. Training has been arranged for staff on medicine administration. Staff described good practices in promoting residents privacy and dignity and residents said that they are happy with how they are supported. Residents were appropriately dressed and well presented. Residents said that their clothes are kept nicely clean and if staff see a spot on them they take them and clean them. The Hollies DS0000066387.V293408.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, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home matches their expectations. Residents maintain contact with family and friends. Residents are usually helped to exercise control over their lives. Residents receive a wholesome and balanced diet. EVIDENCE: The daily routines can be varied by residents if they wish. One member of staff has responsibility for activities and there are two recording systems in operation to record when residents take part in activities, only one of which was available at the inspection. It would be simpler if there was only one system in operation. Residents said they enjoyed the activities but would like these to be more frequent; in particular they had enjoyed an exercise session, which is no longer taking place. The provider and manager explained that the person had stopped doing these sessions and they were looking for someone to replace them. Arrangements are made to meet residents’ religious needs including a regular communion service. The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 12 Records showed that residents use facilities in the local community and residents talked about their visitors. The provider said he is planning to create an additional dining area where residents can entertain their friends and relatives for meals if they wish. Staff described how choices of everyday living are promoted to residents, although said one resident would like to wear a certain jumper all the time, but this is not complied with for fear relatives will feel the resident is not being cared for properly. This was discussed with the manager who said that she would respect the resident’s wishes and discuss it with the relatives. A four week menu was seen in the kitchen but the menu record book showed that this is not being stuck to. The meals provided showed a varied and balanced diet is provided and residents said that they the food is very good. The Hollies DS0000066387.V293408.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to. Residents are protected from abuse. EVIDENCE: The home has a complaints procedure for use by residents and relatives if they are not happy with something within the home. The manager said that there have not been any complaints made. Staff said they were not aware of the complaints procedure, which the manager felt that they were. Residents said that they would raise anything they were not happy about with the manager. There was a copy of the Adult Protection Procedures in the home and staff said that these had been discussed as part of their initial training. Residents and staff said that they had not witnessed any person being mistreated. The Hollies DS0000066387.V293408.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 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 safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: A gardener/handyman is employed to keep the home in good order and staff record anything they see needing doing in a jobs to be done book. The new provider has re carpeted some areas and is compiling a list of priorities to be done, including updating furniture and decorating. Staff said that they thought the building was homely and residents said it had character and they liked the view from the front of the house. There are two ramped entrances to the building and all areas of the home are accessible to wheelchair users. There is a passenger lift for access to other floors. The laundry is located on the top floor and is well organised. The home was clean and tidy and residents said it was always kept like this. The Hollies DS0000066387.V293408.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, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. The manager could not demonstrate whether residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The new provider has increased the staffing levels by 25 hours a week resulting in their being three care staff and a domestic on duty in the mornings, and three care staff in the afternoon. There are two waking staff on duty overnight. Staff said it was busy on late shifts particularly with the number of baths needed. Residents said that they felt there were sufficient staff on duty to see to their needs and that they are run off their legs. All care staff are female but the manager and provider said that arrangements would be made to accommodate a residents preference for a male carer. The majority of the staff team have now completed or in the process of completing National Vocational Qualification level 2 or above. A recently appointed member of staff said that the manager has spoken to her about doing a level 2 and she is intending to do so. The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 16 The member of staff said that she had undergone a TOPPS induction when starting and since then has had some in house training and attended a course on care planning. The manager said that she is in the process of sorting out the required mandatory courses and updates needed. Residents said that the staff seem to be trained to them. The home has an equal opportunities policy, which is followed when recruiting new staff. The manager was unable to locate the information required for all staff working within the home and as the administration officer was not working this could not be produced. A Criminal Records Bureau check arrived in the post the morning of the inspection for a recently started member of staff and the manager said that a POVA check had been obtained prior to the member of staff starting. Staff said that they had completed an application from, provided 2 references and had a Criminal Records Bureau check prior to starting. The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 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, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a suitable manager employed to run the home. Residents require greater opportunity to express their views on how the home is run. Better safequards are needed for residents’ finances. The health, safety and welfare of residents are not fully protected. EVIDENCE: The manager has been in charge of the home for a number of years and has completed National Vocational Qualification level 4. Residents said they thought the home was well run and they had not been affected by the change in ownership. The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 18 The provider has been speaking to residents about their views on the home whilst carrying out the Regulation 26 inspections. He has also written to all residents and their relatives giving them his email address and phone numbers saying he can be contacted at any time. Residents said that they had not ever completed a questionnaire about the home and had not been asked fro their views. In addition their must be a system for reviewing and improving the quality if care within the home. There are arrangements in place for residents finances to b managed by themselves or their relatives with the exception of one resident where the home helps manage the personal allowance. The records kept of this do not include signatures witnessing any transaction. One resident said that he manages his own finances and another said that this is done by her son. The fire log showed that the required safety checks and tests are carried out at the correct frequency. Residents said that they hear the fire alarm being tested. The home has not had an assessment as to the safety measures needed to prevent the risk of Legionella and temperatures of hot water storage are not being checked. The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 20 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 Standard OP7 Regulation 15 13 Requirement The registered person must ensure that all residents have an individual plan of care. The registered person must ensure that the correct medicine administration procedures are followed The registered person must ensure that information on staff recruitment is available for inspection The registered person must ensure that all staff have been provided with the required training The registered person must ensure that there are systems in place for reviewing and improving the quality of care within the home The registered person must ensure that there are systems in place to safeguard residents’ finances. The registered person must ensure that the required safety checks are carried out to prevent the risk of Legionella. Timescale for action 01/07/06 01/06/06 OP9 3 OP29 19 01/07/06 4 OP30 18 01/09/06 5 OP33 24 01/09/06 6 OP35 17 01/07/06 7 OP38 12 01/07/06 The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 21 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 OP12 Good Practice Recommendations The registered person should combine the activities records so only one system is in operation The Hollies DS0000066387.V293408.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 DS0000066387.V293408.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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