Inspection on 08/06/05 for The Hollies

This inspection was carried out on 8th June 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 11/10/05

The Hollies 25/01/05

The Hollies 11/08/04

The Hollies 23/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Hollies Ferriby Road, Hessle East Yorkshire HU13 0HT Lead Inspector Ros Sanderson Unannounced 8 June 2005 09.30 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 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 J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Hollies Address Ferriby Road, Hessle, East Yorkshire, HU13 0HT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01482 643293 01482 627438 Humberside Independent Care Association Limited Mrs Margaret Walker Care Home 48 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (48) of places The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25.1.05 Brief Description of the Service: The Hollies is a care home providing personal care and accommodation for up to 48 older people some of whom may have a dementia care need. The home is owned and operated by Humberside Independent Care Association which is a not for profit organisation. The home is located on a main road in Hessle, west of the city of Hull. There is access to local shops, public houses and transport. The home occupies a purpose built property set out on two floors. All service user accommodation is located on the ground floor. All bedrooms are for single occupancy and some of these are companion rooms that are linked by a door and are suitable for couples or service users choosing to use them. They may be used as a twin room and a sitting room. Many of the bedrooms have ensuite facilities. Service users have the use of lounge and dining facilities and several courtyard gardens that are safe for their use. There is also a large formal garden for their enjoyment. There is plenty of car parking at the front of the building. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day and lasted for six hours including planning and preparation time. The inspection process involved discussions with service users and their families. Discussions with the manager and staff, looking at service user and staff records and inspection of health and safety records. In total, seven service users, two relatives, five staff and the manager were spoken with. The records of five service users were looked at including recent admissions and records of four staff including those recently employed were looked at. A tour of the premises was carried out and all areas of the home were looked at. What the service does well: What has improved since the last inspection? Since the last inspection the home has employed an activities organiser who has made a great difference to the lives of the residents. They all spoke highly of activities available within the home. Residents have access to a wide range of activities and are able to choose which ones they participate in. Activities are available on every day of the week. The manager has made arrangements for controlled drugs to be recorded correctly in a controlled drugs register to further safeguard residents in relation to medication. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 standard(s) 3 Residents living at the Hollies can be assured that their assessed needs will be met. EVIDENCE: The care plans contained a detailed pre admission assessment that had been completed with the co-operation of the resident or their representatives. Signatures were present to evidence this. Two service users confirmed that they had been visited prior to admission and detailed discussions had taken place regarding their needs and wishes. The registered manager stated that no resident was admitted without first having a needs assessment and if this was not possible then it was carried out as soon as possible after admission to ensure needs could be met. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 standard(s) 7,8,9 Healthcare needs are identified and plans are in place to show how these will be met. Medicines are handled and administered safely. EVIDENCE: Care plans looked at showed that they are developed initially on the pre admission needs and wishes assessment. All staff contribute to the plans and the plans are reviewed monthly by the home. Evidence was seen of residents and their family’s involvement. Residents admitted under the care management approach also have annual reviews and families are involved at this stage. A relative explained how she is invited to reviews and given written feedback of any discussions. She said, ‘My mum is well looked after. She only likes female carers and the staff make sure that this happens. She is always treated well. Risk assessments are in place within the care plans and control measures are identified and put in place for any risks to the service users. Service user agreement is obtained for these assessments. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 10 Since the last inspection a controlled drugs register had been obtained and this was used to record Temazepam administration. All staff that deal with medicines are given training in the safe administration of medicines. The manager was in the process of arranging further training for all staff. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 standard(s) 12,13,14 Service users are happy with the lifestyle they experience, maintaining contact with family and friends and choosing how they spend their time and with whom. EVIDENCE: Residents who were spoken with expressed satisfaction with the lifestyle they experience at the Hollies. All residents spoken with had good family contact and often had daily visits and trips out with families. Relatives spoken with were also pleased with the daily activities available within the home and said how they are always made to feel welcome and that staff were able to give time to discuss any concerns they may have. There is an activity co-ordinator employed at the home and she ensures that there is a seven day programme of activities available for all residents. These activities are displayed on the notice board so that residents and their relatives are aware of what is happening in the home on any one day. This information is given verbally to residents by care staff and the activities co-ordinator. A record is kept of residents likes and dislikes in relation to activities and although there is always something happening in the home residents are not pressured to join in if they don’t wish to. A separate lounge is available for residents wishing to smoke. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 12 Residents are able to take communion monthly within the home and anybody wishing to attend church services are facilitated with this by the staff or their families. The home has the use of a minibus and a full programme of outings had been arranged for the year. Residents expressed their enjoyment of trips out. Comments from residents included, ‘I like living here, there is always something to do’ ‘I go to bingo every week with my daughter and then go to her house for tea’ ‘I love the trips out. We have been as far as Bridlington’ The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 standard(s) 16 Residents and relatives feel they are listened to and complaints acted upon. EVIDENCE: The complaints procedure is given to all residents and relatives before or at the time of their admission. The procedure is then explained verbally to them. A service user said that they knew who to approach if they had a complaint and that they felt confident to do this. A relative stated that she had made complaints before and they had always been treated seriously and that she had been informed about outcomes. She felt confident to make a complaint and stated, ‘The staff do not take offence if you complain, and most of the time they are upset things may have gone wrong’ The complaints book was looked at and it showed that complaints had been dealt with in the agreed timescale and that outcomes had been passed on to the complainant and recorded in the file. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 standard(s) 19,20 & 26 Residents live in a safe, comfortable environment that is clean and hygienic. Refurbishment is required to one area of the home. EVIDENCE: The layout of the home ensures that residents are safe. Residents are able to enjoy the outdoors and sit in pleasant surroundings in the courtyard gardens. The main garden is well kept and stocked with pleasant shrubs for residents to enjoy. Garden furniture is provided so that residents can sit out when they wish. The home complies with the fire authority requirements and has fitted ‘door guards’ to resident’s rooms when they wish their doors to be kept open. The communal non smoking lounges and sitting areas are well furnished and pleasantly decorated. The furniture in the smoking lounge needs refurbishment or replacing as there are holes in the fabric of the chairs and some chairs and footstools are badly soiled. The home is clean and free from any bad odours. Staff stated they are given training in infection control and that they have adequate supplies of personal The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 15 protective equipment. This was evident when observing staff working during the day. There are plenty of hand washing facilities available for staff, residents and visitors to the home. There is a dedicated laundry assistant employed who makes sure all laundry is washed appropriately. She was able to explain the requirements for washing soiled laundry. Residents and relatives spoken with said that the laundry is always washed and ironed well and returned promptly to them. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Residents are cared for by staff that are safe and have been trained to do so. EVIDENCE: Staff records showed that full application forms are completed for each person applying to the home. Written references are taken up and CRB’s are obtained for each member of staff. Staff are not started in post until all checks are complete. Staff spoken with confirmed these arrangements. Prior to commencing employment all staff undergo an induction training week that meets the national training organisations requirements. Further ongoing training is arranged in order for staff to meet identified resident’s needs. Although the provider had informed the registered manager verbally of the outcomes of staff pre employment checks, there was no written evidence on the files to support this. A requirement was made that written confirmation of checks is obtained and kept on each member of staff’s files. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The registered manager ensures that the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Certificates relating to the system and appliance checks within the home are all current and the manager deals with issues promptly to ensure this continues. Staff are regularly supervised to ensure training needs are identified and met and that mandatory training is current for all staff members. Robust training within the organisation ensures that safe working practices are employed at all times and residents are safe. Generic and specific risk assessments are in place and are reviewed on a regular basis evidenced by signatures. The manager is aware of her responsibilities regarding reporting of incidents and accidents under the Care Standards Act 2000 and RIDDOR regulations. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 2 x x x x x 3 STAFFING Standard No Score 27 1 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 19 NO Are there any outstanding requirements from the last inspection? 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 29 Regulation 19(4(b)) para 7 sch 2 Requirement The registered person must ensure that there is written evidence of POVA 1st and CRB checks held in the home in respect of each member of staff employed Timescale for action 21/6/05 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 20 Good Practice Recommendations Consideration should be given to the replacement or renewal of furniture in the smoking lounge. The Hollies J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection York Area Office Unit 4, Triune Court Monks Cross York, YO30 6NL 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 J53_J04_S19744_The Hollies_V229295_070605_Stage 4.doc Version 1.30 Page 21 - 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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