Inspection on 06/12/06 for The Hollies

This inspection was carried out on 6th 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 30/11/07

The Hollies 02/12/05

The Hollies 17/08/05

The Hollies 29/01/05

The Hollies 11/05/04

The Hollies 21/01/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE The Hollies 11 Queen Edith`s Way Cambridge CB1 7PH Lead Inspector Andy Green Key Unannounced Inspection 6th December 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 DS0000015232.V322458.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 DS0000015232.V322458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 11 Queen Edith`s Way Cambridge CB1 7PH 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) 01223 245774 01223 414077 Guy Curtis Care Limited Sandra Catherine Margaret Bailey Care Home 22 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (22), Physical disability (1) The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 DEE, 4 MDE subject to a maximum total from these 2 client groups combined of not more than six of the total 22 residents and 1 PD. 2nd December 2005 Date of last inspection Brief Description of the Service: The Hollies is a residential service for older people over 65. The home provides accommodation for up to 22 service users, some of whom may have dementia care needs. The home is situated in an established residential area on the outskirts of the city of Cambridge. It is within easy reach of the city centre, Addenbrookes Hospital and close to good road and rail links. The home provides accommodation on two floors and there is a passenger lift providing access to the first floor. All of the bedrooms are offered as single occupancy with seven having en-suite facilities. There are adequate bathroom facilities available. The home offers generous communal space with two separate lounge areas and a dining room. There are attractively maintained gardens to the front and rear of the property. The charges range from £570 - £620 per week CSCI reports are made available to service users and relatives on request. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector, Andy Green undertook this unannounced inspection on 6th December 2006. The inspector met with the manager, proprietor, care staff, service users and a relative to gather views regarding the services offered in the home. A number of records were inspected including care plans, training records, fire records and staff files. A tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 6 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 DS0000015232.V322458.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 DS0000015232.V322458.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): 1,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have access to good information, and can make an informed choice regarding the home’s services EVIDENCE: The Statement of Purpose and Service Users Guide has been updated since the last inspection to include the manager’s details since she became registered with CSCI. The provider has also updated his details now that he is no longer the registered manager. The home continues to receive referrals from “Home Finders” and the local authority and the manager and a member of the care team continue to visit prospective service users to carry out a needs assessment as required by this standard. The manager stated that the majority of service users are privately funded. The home does not provide intermediate care. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 9 The manager stated that there have been no changes made to the assessment procedure since the last inspection however, she stated that the assessment process is reviewed throughout the year to ensure its effectiveness and that appropriate information is received. Prospective service users and their family/relatives are encouraged to visit as part of the assessment process, prior to admission and when they move in to the home. This was also evidenced during the inspection when a new service was being admitted to the home. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive appropriate health and personal care to meet their assessed needs. Medication is administered and recorded accurately. EVIDENCE: The care planning system has been reviewed and a new care dependency audit sheet has been implemented to monitor healthcare needs. The manager has also implemented an hourly monitoring form for service users who are being cared for in bed. Three service plans were seen and information is presented in an accessible manner for recording and reviewing care provided in the home. Three service user files were inspected and contained information regarding the individual service users assessed needs. However there needs to be more detail regarding the care interventions that care staff need to give to ensure that care and support needs are fully met. This was raised with the manager and she stated that she would ensure that more detail is provided in care plans. Consequently a requirement will be made regarding this issue. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 11 There was evidence that reviews are carried out regularly with any changes in care documented. It was also noted that a photograph was missing from a service user file and this will be a further requirement. Service users continue to receive visits as required from a variety of healthcare professional including GP’s, district nurses and a chiropodist. The home’s relationship with local GP surgeries and district nurses remains proactive to ensure that healthcare needs of service users is maintained and this was clearly evidenced during visits being made by a local GP visiting service users during the inspection. Three relatives of service users confirmed that they are always are informed of any significant healthcare changes. Medication administration records were inspected and were accurate. Controlled medication is stored securely and administration records are double signed in a separate book. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. Staff provide appropriate support to ensure that service users have access to activities appropriate to their needs. EVIDENCE: The home provides a variety of activities throughout the year. There are a number of musical entertainers who provide events throughout the year and birthday parties and summer fetes continue to be held. There was an Ascot style party held in the summer and full programme of Christmas events are planned. The manager stated that she is in the process of recruiting a part time activities co-ordinator to develop further individual and group activities in the home. Relatives are encouraged to visit regularly. This was most evident during the inspection with a number of relatives visiting in the lounge, going out for lunch and also to assist their relative to access hospital appointments. The ambiance of the home remains lively and busy with service users and staff socialising with each other in the lounge. A lively hairdressing and manicure session was also in progress with the hairdresser who visits three times per week. Light exercise sessions are also arranged in the communal lounge for service users. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 13 A monthly newsletter continues to be circulated in the home, which gives details of forthcoming events in the home. There is a varied range of meals offered throughout the day and service users have a choice of alternatives to the suggested menu choices. Snacks and drinks continue to be made available at all times during the day. Four service users spoken to confirmed that the food was of a good standard and they were complimentary about the services and support that they received in the home. This view was also echoed by relatives who felt that the care and support provided was of a high standard. One relative did however raise a slight concern about some meals that they had witnessed but the manager had resolved this. Comment cards received by CSCI were complimentary and views expressed were shared with the manager. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 14 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 has a complaints process to make sure that service users have their complaints or concerns listened to and acted upon properly. Service users are protected from abuse. EVIDENCE: The home has a clear complaints procedure, which includes agreed timescales to ensure that all complaints are fully investigated and actioned appropriately. There have been no changes to the complaints procedure since the last inspection. The home has not received any complaints since the last inspection. CSCI has also not received any complaints regarding the home. The home has a satisfactory policy regarding Adult Protection, which is in line with the Local Authority policies. The manager is now a Key Practitioner via the local authority POVA trainer and she cascades training to the staff team on a regular basis to ensure that service users are protected from abuse. Care staff confirmed that they had received POVA training in the last twelve months. Care staff are clearly committed to the care of service users and they were observed to speak in a respectful, sensitive and friendly manner. Relatives spoken to during the inspection also confirmed this to be the case. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 15 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): 19,20,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is suitable for the needs of those living in the home but some improvements are required. EVIDENCE: The premises continue to be well maintained and there is an ongoing maintenance and decoration programme in place. There are plans to redecorate the downstairs long corridor. This work will be incorporated in the planned extension to the dining area, communal areas, and additional ensuite facilities commencing in the New Year. The home is kept in a clean and tidy condition and was free from odours. The gardens continue to be well presented and maintained throughout the year. Service users and visitors to the home enjoy spending time in the gardens adjacent to the main lounge during the warmer months of the year. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 16 Service users can personalise their bedrooms and are encouraged to bring personal items and furniture as long as health & safety requirements are met. Bedrooms seen during the inspection were well decorated and reflected service user’s style and preferences. The manager stated that the home continues to receive advice from an Occupational Therapist when required regarding the changing physical and mobility needs of service users. The kitchen is presented in a hygienic and organised manner and areas of ceiling have been redecorated since the last inspection. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 17 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’s recruitment policy and processes makes sure that service users are protected from harm. Training is provided to make sure that care staff are competent to deliver care to the service users they support EVIDENCE: All staff are issued with job descriptions and clear details of their areas of responsibility. The home has a thorough recruitment procedure including CRB/POVA checks and appropriate references taken up before employment commences. The home is fully staffed at present. There are three carers on each shift along with the manager and two staff at night. There are also three domestic staff and one cook working in the home each day including weekends. The home’s training files was seen and there was evidence to show that staff members continue to regularly receive a variety of training in health and safety and elderly care issues as part of an ongoing process throughout the year. The manager monitors training and records showed updates to ensure that safe working practice are regularly organised. Recent training included first aid, POVA, moving and handling and food hygiene. The manager stated that at least 75 of staff had completed/working towards NVQ at levels 2 & 3. This was further evidenced through conversations with three staff that stated that they received regular training including NVQ level courses. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 18 The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 19 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): 31,32,33,34,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and the manager provides supportive leadership and guidance to staff to ensure that service users receive high quality care. EVIDENCE: The manager continues to provide clear management in the home and is keen to include the views of the staff team to develop the services and care provided for service users. She has completed an NVQ level 4 in Management & Care. The provider remains actively involved in the home on a daily basis and provides ongoing support to the manager. Staff spoken to during the inspection confirmed that they were well informed and supported by the management in the home. It was noted however, that staff supervision needs to be improved to ensure that staff receive at least six recorded sessions during the year as recommended in the National Minimum Standards. The manager acknowledged The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 20 that this is an area for improvement and she stated that this would be actioned accordingly. Consequently a requirement regarding this issue will be made. The manager stated that four new policies have been implemented in the home since the last inspection; Selection and Recruitment, Risk Assessment for New & Expectant Mothers, Risk Assessment of Stress at Work and Ageism Policy. Two of the service users personal money and records were inspected and were accurately administered. A new fire alarm system has been installed in the home and adequate fire alarm/emergency lighting testing is carried out. There are contracts in place for equipment /maintenance checks throughout the year. Records were not inspected on this occasion. The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 3 X 3 3 3 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 3 3 3 3 2 2 3 The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 22 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 Standard OP7 Regulation 15(2)(b) Requirement Guidelines for staff need to be clearly documented in care plans to ensure that assessed needs are fully met Arrangements must be in place to ensure that staff receive adequate supervision throughout the year. All service users records must include a recent photograph as specified in Schedule 3 of the Care Homes Regulations 2001. Timescale for action 28/02/07 2 OP36 18(2) 28/02/07 3 OP37 17 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hollies DS0000015232.V322458.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 DS0000015232.V322458.R01.S.doc Version 5.2 Page 24 - 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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