Inspection on 05/12/06 for The Hollies

This inspection was carried out on 5th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Hollies 08/12/05

The Hollies 13/07/05

The Hollies 31/08/04

The Hollies 20/05/04

Similar services:

Snydale Care Home

Abbey The

Whiteley House

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Hollies 11 Eastmoor Road Wakefield West Yorks WF1 3RZ Lead Inspector Gillian Walsh Key Unannounced Inspection 5th December 2006 9.45 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 DS0000006190.V315772.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 DS0000006190.V315772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 11 Eastmoor Road Wakefield West Yorks WF1 3RZ 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) 01924 364462 01924 372167 The Hollies Care Services Ltd Mrs Angeline Richardson Care Home 29 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (29), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (29), Old age, not falling within any other category (29), Physical disability over 65 years of age (19) The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: The Hollies is a privately owned care home providing accommodation and personal care for 29 older persons who are subject to enduring mental health problems or dementia. The accommodation operates over three floors connected by a shaft lift and stair lifts. All bedrooms are single, two of which have en-suite facilities. The home has a variety of communal facilities including 3 lounge areas, 2 dining rooms and a sun lounge. The home is a converted and extended Edwardian property close to the centre of Wakefield which provides the nearest community facilities. The home has a small garden to the front and rear and a small car park. The manager informed the Commission that the charge for living at the home, as of December 2006, is £359 - £368 per week with extra charges made for hairdressing, newspapers and private chiropody. Information about the home is available within the Statement of Purpose and the Service User Guide which are given to all residents and prospective residents. Details of the Commission for Social Care Inspection are included within the Service User Guide as is the summary of the last inspection report. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection, one inspector from the Commission for Social Care inspection (CSCI) undertook an unannounced visit to the home. The visit started at 9.45am and finished at 4pm on 5th December 2006. The inspector’s time was spent speaking with residents, relatives and staff, reviewing documentation and taking a tour of the home. Alongside this, the service provider was asked to complete a pre-inspection questionnaire which was returned prior to the site visit. Questionnaires were sent to residents, their relatives, visiting professionals and GPs. 10 residents’ questionnaires were sent out with 0 received back. Of the 9 relatives’ questionnaires sent out, 5 were returned. Of the 8 General Practitioner questionnaires sent, 3 were returned. Of the 5 social worker questionnaires sent, 1 was returned. Questionnaires returned gave positive feedback; one person made a comment that they were more than happy with the care and support provided at the home. As part of this inspection, the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the Service User Guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. In writing this report, information and evidence was not only obtained by way of visiting the home but also from notifications and information obtained by CSCI and from the last CSCI inspection report. In gathering evidence, CSCI undertook case tracking, reviewed documentation, sought feedback from residents and their families, staff, the home’s manager and other relevant stakeholders, and undertook relevant observations and The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 6 discussions appropriate to needs of the service users, taking into account their needs and communication abilities. The inspector would like to thank residents and their relatives and staff for their time and assistance during this inspection. What the service does well: What has improved since the last inspection? What they could do better: • • • • A relevant care plan should always be developed when the results of an assessment indicate that the person concerned has a specific need. Staff should respond quickly to residents who are complaining of pain or discomfort to help give some ease. Systems for administration of medication can be improved. Mealtimes could be better organised to prevent some residents having to wait much longer than others. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 7 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 DS0000006190.V315772.R01.S.doc Version 5.2 Page 8 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 DS0000006190.V315772.R01.S.doc Version 5.2 Page 9 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): 1, 2 and 3. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are not admitted to the home without having their needs assessed by a member of staff from the home and assurances given that these needs can be met. EVIDENCE: The home manager said that all prospective residents are given a copy of the Service User Guide when the pre admission assessment takes place and another copy is given to the family when their relative is admitted to the home. A note of when this is done is made on the admission documentation. The Service User Guide contains a summary of the Statement of Purpose and The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 10 the summary of the last inspection report. Signed copies of contracts and statements of terms and conditions were seen within the residents’ files. The manager said that, whenever possible, she goes out to assess prospective residents; if she is unable to do so, the responsible individual for the home will complete the assessment. Completed pre admission assessments were seen within all of the four care plan files looked at during the visit to the home. The assessments are comprehensive, covering the prospective residents’ physical, psychological and social needs. None of the residents spoken with were able to recall the exact details of their admission to the home or what information they had been supplied with. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 11 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 developed which set out residents personal and social care needs. Health care needs are met appropriately and systems for medication are safe. Residents feel they are treated with respect. EVIDENCE: All of the four residents’ files seen during the visit to the home contained care plans which detailed the individuals’ health and social care needs. Care plans are divided into long and short-term needs and priority areas and, wherever possible, are signed by the resident or their next of kin. To assist with the care planning process, a number of assessments are completed in areas such as nutrition, moving and handling and, wherever appropriate, risk assessments. Generally, wherever an assessment indicates the need for a particular plan of care, this is developed. However, one nutritional assessment showed that the resident concerned had been losing weight steadily over the past year but a The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 12 care plan had not been developed in relation to this, neither had a referral been made about this to the GP or dietician. Care plans and daily records indicated that usually referrals are made to GPs, district nurses, mental health nurses etc as the need arises. Where required, residents are escorted by staff to clinic or hospital appointments and other health care needs such as optical and dental are met either through visits to local practices or through domiciliary visits. All interventions from health care professionals are documented in the daily records. Three GPs completed and returned questionnaires to the Commission, all of which indicated satisfaction with the service but did not contain any specific comments. During the inspection visit, one resident was heard to say to a care assistant that their bottom was hurting; the carer replied that they could be taken for bed rest after lunch. Some time later, whilst being assisted with their lunch, the resident again complained of severe pain in their bottom saying they could “hardly stand it”. The resident was noticed to be sitting on a pressure-relieving cushion. Again the carer said that the resident could go on bed rest after lunch. The care plan for the resident concerned indicated that they had been on bed rest for some time but the manager said they had got up to see the hairdresser that day. Whilst all care was being given as detailed in the care plan, discussion took place with the manager about how staff could be encouraged to act more responsively when a resident is complaining of pain. Systems for storage and administration of medications in the home were checked and appeared safe, although discussion took place with the manager about how systems for the administration of medication could be improved. Most of the people spoken with said that staff were kind and respectful in their approach and confirmed that staff were mindful of their need for privacy. One person said that some staff did not always knock on their bedroom door before entering. This was not observed to be the case during the visit. All residents were nicely dressed and appeared very well groomed. It was evident that, where the resident is unable to manage their own hygiene and grooming, staff give assistance to ensure that that this is done to a high standard. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are happy with their lifestyle in the home and that they can maintain contact with friends and family as they choose. Individual choices and preferences are respected and generally encouraged. Meals are nutritious and appetising with choices offered at each mealtime. EVIDENCE: On the day of the visit one person said that they were waiting to go out. The person explained that their key worker was coming in, on their day off, to take them into town shopping as they wanted to buy a few items of clothing. The key worker, who arrived at the time they had promised, said that this was something they did on a regular basis as residents enjoyed it. The home manager confirmed this and said that staff are paid for this extra time. Also, on the morning of the visit, a group of residents were sitting in the small lounge watching the film “The Sound of Music”. This had been requested by one of the residents and was clearly being enjoyed. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 14 Daily activities are advertised on a notice board in one of the lounges, this was seen to include craft sessions, Bingo, movement to music and various evening events including outside entertainment and cheese and wine evenings. Also a notice had been put up to inform residents of organised shopping trips in the run up to Christmas. The home employs an activities organiser working two days each week. Care staff deliver activities at other times. Prior to the inspection, a concern had been received by the Commission about a resident who spent large amounts of time sitting alone. Time was spent speaking to this person who confirmed that this was their choice but did occasionally join in with activities they particularly enjoyed. Another person said that they also spent time alone in their room but this was their choice. This person also said that they had “a pal” in the home who they spent time with as they wished. Care plans also contained details of individuals’ social and recreational needs. One person who was visiting their relative said that they were always made to feel welcome during their very frequent visits and a relative wrote in a questionnaire “ I am more than happy with the care and support given”. Evidence that residents are offered choice in their daily lives was available in care plans and from observing staff going about their work. One resident proudly showed off their room saying that they had chosen the colour scheme for the recent redecoration. It was, however, of concern that bath lists detailing when residents should be bathed are in use at the home. Staff explained that people could have baths at other times but that the list makes sure that everybody has at least one bath each week. Discussion took place about how this should be achieved without the use of bath lists. All of the residents spoken with said they were very happy with the meals provided at the home. Generally, people take their meals in the dining rooms but can eat in the lounge or in their own room if they choose. The lunchtime meal appeared nutritious and appetising although the mealtime itself appeared a little disorganised with some people getting a little annoyed that they were having to wait much longer than others to be served their meal. Suggestion was made to the manager that this should be looked at to ensure that mealtimes are a pleasurable experience for everybody. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents and their families can be confident that their complaints will be taken seriously and acted upon. Systems are in place to protect residents from abuse. EVIDENCE: Since the last inspection, the Commission has received four complaints (two anonymous) about alleged care practices at the home. All were referred to the home for investigation and have been appropriately dealt with. One is ongoing but arrangements are being made to meet with the complainant to discuss the issues. Two relatives who responded to the Commission’s questionnaire said that they were not aware of the home’s complaints procedure. This is however, included in the Service User Guide and is on the back of each resident’s bedroom door. All of the residents spoken with said they would tell the staff if they had a problem but were unable to discuss specifics about the complaints procedure. One person said there was no point in them reading it as they would not be able to remember what it said. Training records showed that staff have received training in abuse and protection of vulnerable adults and the manager confirmed that all senior staff The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 16 are aware of how to report any suspicion of abuse under Wakefield Council’s own policies and procedures. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 17 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 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 comfortable, well maintained and hygienic environment. EVIDENCE: A tour of the building, including all communal areas and some bedrooms, confirmed that the home is well maintained and that housekeeping is of a high standard. The home provides a comfortable and homely environment with all areas clean and tidy. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by a well-trained team of staff, available in sufficient number to meet with individuals’ needs. Recruitment and induction procedures are in place to protect residents. EVIDENCE: All of the staff at the home receive regular training updates in a number of subjects relevant to their area of work. Staff said that all training opportunities are made known to them and they are encouraged to take these up and to identify their own training needs in supervision and appraisal. The training matrix shows that all staff are up to date with mandatory training and details other training undertaken. Information from the manager was that over 50 of care staff have obtained NVQ level 2 in care, with five staff about to start level 3 and the deputy manager holds level 4. Induction procedures for all new staff include the Skills for Care Council’s common standards and a specific induction to the home. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 19 Both of the relatives who returned the Commission’s questionnaires indicated that they thought there were enough staff on duty to meet residents’ needs and one resident said of staff “they always come when I need them, I don’t have to wait”. Observations during the visit were that staff are available in sufficient numbers and the manager said that extra staff are used whenever the need arises. Four personnel files were seen and included all of the documentation required by regulation to protect residents. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 20 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 and 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 managed by a person suitably qualified and experienced to ensure that the home is properly managed and run in the best interests of residents. Systems are in place to ensure that residents’ financial interests are safeguarded. The health and safety of residents is protected by several systems in place at the home. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home’s manager has many years’ experience of managing a care home and has gained the registered managers award. Views of people involved in the service are sought as part of the quality assurance process within the home and a report on the most recent quality monitoring has been developed and a copy sent to the Commission for Social Care Inspection. Other copies of this report are available in the home. The home only holds personal allowance for two residents. Documentation relating to this was checked and found to be appropriate and in good order. Records relating to maintenance of systems and equipment in the home were checked. The manager also provided information within the pre inspection questionnaire that maintenance checks and appropriate certification of systems within the home are in place and up to date. Records of fire drills indicated that these are held on a regular basis. The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A 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 DS0000006190.V315772.R01.S.doc Version 5.2 Page 23 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 OP8 Good Practice Recommendations Where the outcome of an assessment indicates a specific need or risk, a relevant care plan must be developed. Referral must also be made to the appropriate healthcare professional where the assessment has indicated that an individuals health may be compromised. Staff should respond quickly to residents who are complaining of pain or discomfort to help give some ease. Consideration should be given to how the systems for administration of medication can be improved. Consideration should be given to how mealtimes could be better organised to prevent some residents having to wait much longer than others. 2 3 4 OP8 OP9 OP15 The Hollies DS0000006190.V315772.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 DS0000006190.V315772.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!