Inspection on 08/12/05 for The Hollies

This inspection was carried out on 8th December 2005.

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 05/12/06

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 Unannounced Inspection 10:00 8 December 2005 th 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.V253800.R01.S.doc Version 5.0 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.V253800.R01.S.doc Version 5.0 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.V253800.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: The Hollies is a care home providing accommodation and personal care for 29 older persons who are subject to enduring mental health problems or dementia. The care home is privately owned. The accommodation operates over three floors that are connected by a shaft lift and stair-lifts. All the bedrooms are single, two of which have en-suite facilities. The home has a variety of communal facilities that are used for sitting, dining and activities. 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 Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made over three and a half hours on 8th December 2005. Time was spent speaking with residents, staff and management, checking documentation and taking a walk around the home. The inspector would like to thank residents and staff for their time, assistance and hospitality during the inspection. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 6 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.V253800.R01.S.doc Version 5.0 Page 7 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): 1 Prospective residents and their families have the information they need to make an informed choice about where they wish to live. EVIDENCE: The Statement of Purpose and the Service User Guide have recently been updated and now include details of the home’s security measures, such as a digital lock to the front door, to assist in maintaining the safety of residents suffering from confusion and disorientation. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 8 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, 9 and 10 Appropriate care plans are in place although risk assessments need to give more detailed information. Residents are not protected by the home’s procedures for dealing with medications. Residents feel they are treated with respect. EVIDENCE: A selection of care plan files were seen. Care plans gave good detail of residents’ needs and preferences and what interventions were necessary from staff to ensure that these needs are met. Wherever possible, care plans are signed by either the resident or their representative. Risk assessments are in place but do not contain sufficient detail of the identified risk or controls in place to minimise the risk. Systems for the storage and administration of medication were checked. The MAR (Medication Administration Record) sheet for one of the medications checked indicated that there should be two tablets remaining in stock but only The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 9 1 tablet was left in the box. During the visit, the next month’s supply of medications were being booked in and return medications were being sorted out for delivery back to the pharmacy. This process was being carried out in one of the resident’s bedrooms and had all been left unattended in the room. Although the room was locked, it is not appropriate or safe to have large amounts of medications left out in a room to which several members of staff and the occupant of the room have access. Systems for the administration of controlled drugs were checked and found to be safe. All of the residents spoken with, who were able to express an opinion, said that staff at the home treat them with kindness and respect, one person said that the staff “could not do enough” for them. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 10 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): 14 Residents are happy with the choices available to them at the home. EVIDENCE: Residents’ personal preferences and individual choices are included within the care plans. Residents said that they were free to choose how they spent their time and that they were offered choices with regard to meals. It was noted that, when mid morning drinks were being served, only tea was available on the trolley, all of which had already been poured into cups and milk added. The manager said this was to prevent having hot teapots on the trolley, which could cause injury to residents. The manager may wish to consider purchasing thermos jugs, which can be used to serve freshly made hot drinks without risk to residents. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 11 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): 18 Policies and procedures within the home are followed to protect residents from abuse. EVIDENCE: Staff training is ongoing at the home in relation to protection of vulnerable adults, this includes the training given by Wakefield Metropolitan District Council regarding their own procedures for the protection of vulnerable adults. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 12 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 The home provides a pleasant, safe and well-maintained environment. EVIDENCE: A tour of the home confirmed that residents live in a safe, well-maintained, clean and tidy environment. Issues raised at the last inspection regarding the need for radiator covers are now being dealt with, most are in place and others are being fitted as they are delivered. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 13 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): None of the above standards were assessed on this occasion. EVIDENCE: Standards regarding staffing were all assessed at the last inspection. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 14 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): 35 and 38 Residents are safeguarded by the accounting and financial procedures of the home. Policies and procedures in place at the home promote the health and welfare of residents and staff. EVIDENCE: The home looks after the monies of two residents. Documentation relating to this money and the balances held were checked and correct. Accounts for both of these residents are checked by an accountant. Documentation regarding promotion of the health and safety of residents and staff was fully checked at the last inspection when a concern was raised about The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 15 the frequency of fire drills held at the home. Records now indicate that fire drills are being carried out at least six monthly. The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 The Hollies DS0000006190.V253800.R01.S.doc Version 5.0 Page 17 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 08/12/05 arrangements for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home. Requirement 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 DS0000006190.V253800.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 DS0000006190.V253800.R01.S.doc Version 5.0 Page 19 - 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. 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