Inspection on 04/02/08 for The Hollies Rest Home

This inspection was carried out on 4th February 2008.

CSCI found this care home to be providing an Adequate service.

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 Rest Home 17/01/09

The Hollies Rest Home 07/11/05

The Hollies Rest Home 21/06/05

The Hollies Rest Home 21/03/05

The Hollies Rest Home 23/11/04

The Hollies Rest Home 09/03/04

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

CARE HOMES FOR OLDER PEOPLE The Hollies Rest Home 14/16 Park Road Southborough Tunbridge Wells Kent TN4 0NX Lead Inspector Gary Bartlett Unannounced Inspection 4th February 2008 08:00 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 Rest Home DS0000024029.V358743.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 Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Rest Home Address 14/16 Park Road Southborough Tunbridge Wells Kent TN4 0NX 01892 535346 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) manager.hollies@regalcarehomes.com www.regalhomes.com Regal Care Homes Ltd Care Home 31 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (1) of places The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care of one service user is restricted to one person whose date of birth is 21/12/1940 18th September 2006 Date of last inspection Brief Description of the Service: The Hollies is a care home providing personal care and accommodation for 31 older people who are experiencing dementia. It is owned and operated by Regal Care Homes Ltd. The home employs care staff that work a rota giving 24 hour cover, which includes waking night staff. In addition to the care staff there are ancillary staff and a handyman. The home is located in Southborough, near Tunbridge Wells. It is close to shops and a bus route to the town centre of Tunbridge Wells or Tonbridge. The home provides accommodation arranged on three floors. The premises are detached. There are three lounge/dining rooms on the lower ground floor and a conservatory. There are bedrooms on all three floors. There are gardens to the rear and parking at the front. The fees range from £470 to £650 Extra charges are made for: - Hairdresser prices according to service; Chiropodist £10; Papers / magazines / toiletries at cost; Transport to and from hospital varies approx £7.50 per visit. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in The Hollies on 4th February 2008 from 8:00 am until 5:15 pm. During that time the Inspector spoke with some residents, 3 visitors, and some staff. Due to the nature of the service provided, it is difficult to reliably incorporate accurate reflections of residents’ views of the service in the report. Judgements about quality of life and choices were taken from direct observation and by discussion with the Manager and staff, inspection of records and a tour of the building and grounds. The Commission had not received a completed Annual Quality Assurance Assessment from which information could used to inform the inspection process. A number of survey forms were received from residents, relatives, staff and care managers prior to the inspection. Some statements made are quoted in the text of the report. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at The Hollies prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. The Director of Care and Regional South Area Manager arrived during the inspection. The Managers and staff gave their full co-operation and help. What the service does well: Residents say they enjoy living at The Hollies and are very happy here. There is an open and friendly atmosphere and visitors are made welcome. Staff are caring and interact with residents well. Residents enjoy the meals and the food is of a very high quality. Staff are good at helping new residents to settle in. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 6 The Manager is qualified, experienced and has high expectations of the standards of care for residents. What has improved since the last inspection? What they could do better: Residents’ health and welfare would be better promoted if care plans were clearer and more directive. The hand-written dosages on Medication Administration Record charts must be double signed to be sure they are a true and accurate copy of the prescriber’s intentions. All medication, from whatever source, received into the home must be recorded, together with a complete record of all medication returned to the resident on discharge or returned to the pharmacy for disposal. Permission must been obtained from the occupant of the bedroom used for hairdressing and from their representative, for this practice to continue. Ideally hairdressing should be done in a separate room. The unused water pipes that have been left projecting from a wall in the dining room must be removed for residents’ safety. Parts of the home are in need of redecoration and refurbishment. All parts of the home, including all bedrooms, must be free of offensive odours. Staff must not work excessive numbers of consecutive shifts. Such practices can result in fatigue that compromises the staff member’s competency and The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 7 may place residents at risk. A record must be kept of the shifts actually worked by all individuals as required by Regulations. A review of staff training needs must be undertaken and appropriate training provided where necessary to ensure staff are able to meet the needs of the service users at the home. The home must be able to produce evidence of an induction programme undertaken by agency staff. 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 Rest Home DS0000024029.V358743.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 Rest Home DS0000024029.V358743.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): 3, 4, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good pre-admission procedures so that residents can be confident the home can meet their needs. The home must ensure the information gathered is always passed to staff promptly, so they know how new residents care needs and how to meet them. EVIDENCE: Regal Care Homes Ltd has sound policies and procedures for the assessment and admission of residents. A pre-admission assessment is made of each prospective resident to ensure the home can meet his or her needs. The Manager would usually visit the prospective resident in their home or hospital to ensure the necessary information was current and accurate. Prospective The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 10 residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice is sought from external sources where required. The pre-admission assessment would normally be used as the starting point for a care plan for each resident. In one sample looked at, the care plan has not been completed and made available to staff 4 weeks after the person had been admitted to the home. Consequently, staff do not have clear indicators of this person’s needs or how they are to be met. The Manager undertook to ensure this care plan is written in the soonest possible time. As detailed later in this report, the home would find it difficult to readily provide evidence that all staff have the skills necessary to meet residents’ needs. Residents or their families are able to visit The Hollies before moving in. They also said staff had been very helpful in assisting them to settle in. Intermediate care is not offered at the home. The Hollies Rest Home DS0000024029.V358743.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of care offered to service users is compromised because care plans and records of care are not consistently maintained to reflect the quality of care given. More consistent adherence to guidelines for the administration and storage of medicines would better protect residents. Residents’ health needs are met with good liaison with relevant health care professionals. EVIDENCE: Each resident has a care plan and four were inspected in detail. The information contained is not always comprehensive or directive as to how The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 12 needs are to be met. For example, one resident’s care plan does not detail what type of lifting hoist and slings are to be used at different times to suit their needs and preferences. As, mentioned earlier in this report, one resident’s care plan has not been completed and made available to staff four weeks after their admission to the home. The care plans inspected do not show that staff are regularly monitoring residents’ weights. The Manager has been in post for a short while and is planning a review and overhaul of all the care plans. She is aware that records of daily care need to be more informative to comprehensively reflect the service given. In one example seen it is not easy to see track how support has been given in repose to a reported health condition. The Manager said she is planning to address this by regularly monitoring them and giving staff guidance as necessary. Staff spoken with generally have a good understanding of residents’ individual preferences. There is a key worker system that should contribute to an effective exchange of information about residents’ health and welfare. It is evident from discussion with residents, their visitors and staff that residents have access to health care professionals as necessary. During the inspection, the Manager was heard to give a resident’s relative very good support and guidance during two telephone conversations and to liaise with another agency on that person’s behalf. Survey forms completed by relatives included the comments: • “Information promptly supplied especially when there is a sudden change in condition”. • “Good reaction to various changes in health and condition of (resident)” • “ Considerate attentions and proper care” Survey forms completed by health professionals included the comments: • “Updates on progress/concerns/well being”. • “Good at seeing the individual and individual needs rather than offering bland “one size fits all service””. The Manager stated medicines are only administered by staff that have been trained and this was confirmed by staff spoken with. There is a relatively small number of staff trained and this means that, sometimes, a trained staff member stays later than their rostered shift to administer medicines. The management recognises this is not ideal and is intending to recruit and train more staff. Medicines were seen to be given in accordance with good practice guidelines at lunchtime. Most Medication Administration Record charts are computer generated by the pharmacist but some are hand written. These are not being signed by the person completing them and countersigned by a second person checking their accuracy. The records of medicines received are not being kept. These would be required for audit purposes. The Manager undertook to address these matters to lessen the potential risk to residents. The area used for the storage of medicines is cramped. It is, as the Director of The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 13 Care says “a cupboard”. Staff working there have to do so in the corridor, causing obstruction. There are not dedicated hand-washing facilities. The temperature of the cupboard is being monitored. Nobody living at the home is self-medicating. Residents and visitors spoken with feel that staff are kind and gentle, this was confirmed by observation and discussion with visitors. Staff are generally considerate of the age of residents and promote their dignity. Although appreciative of staff efforts, a visitor expressed concern that a resident is sometimes dressed in another person’s or ill-fitting clothing. The Manager undertook to remind staff of their responsibility in this to ensure it does not happen again. This negated the need to issue an Immediate Requirement Notice. When the hairdresser visits each week, it is custom and practice they use a certain bedroom to attend to all their customers. The Director of Care stated permission had been obtained from the previous occupant of the room used but had not been sought from the current occupant. The bedroom’s occupant is not able to use their room at such time and their privacy is potentially compromised. The home must obtain the permission of the resident and their representative for this practice to continue. Ideally, there should be a separate room for hairdressing. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service Residents are able to maintain contact with family and friends. They would benefit from there being more activities available Residents enjoy the meals from menus that offer a choice of good quality food. EVIDENCE: The Hollies cares for people with varying degrees of dementia and lifestyles can be very challenging for some. Residents are offered choices where practical. When choice is not possible, support is given taking into account each resident’s known preferences and sensibilities. The staff member who is assigned to engage the service users in activities is currently off sick. In their absence, this is done by other staff if they have the The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 15 time. Staff working at the home have not received specific training in providing meaningful activities for people with dementia. There is an activity board that displays what is happening and when. A recent event has been the 100th birthday of a resident, celebrated with their friends and family. The Manager is very keen that residents’ individual interests are catered for where practicable and has started asking individuals their preferences. The Hollies has an arrangement where they have the use of a mini bus for occasional trips out. During the inspection, some residents were enjoying a visit by the hairdresser. The hairdresser visits each week and has a very good rapport with residents, their relatives and staff. A notice board provides information about advocates and other relevant information is available. Visitors say they feel welcome and can visit at any reasonable time. During the inspection a number of visitors were seen in the home and the visitors book records regular visits by families, friends and others. The design of The Hollies provides seating areas within various communal areas where residents can entertain their visitors, in addition to the privacy of their own room. Meal times are set for practical reasons but can be flexible to accommodate residents’ needs as necessary. Residents are complementary of the food served and say their tastes are met as best possible with a choice of menu always being offered. The meals are generous in portions and look appetising. Because they are brought to the dining room pre-plated, account is not taken of individual appetites. A large dinner can be off-putting to someone not very hungry or unwell. The Manager explained they are intending to improve the way options are made to residents so they can make a more informed choice. Mealtimes are relaxed; staff are patient and helpful and allow residents the time they need to finish their meal comfortably. Hot and cold drinks are available through out the day, as well as snacks. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 16 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 relatives have access to a sound complaints procedure. There are systems to ensure residents are protected from abuse. EVIDENCE: Residents and relatives state they are satisfied with the service, feel safe and well supported by the Manager who has their welfare as a priority. The complaints procedure is readily available to residents and their relatives. People spoke with at the home say they feel confident they would be listened to and any necessary action would be taken. The Director of Care said there has been one formal complaint received and this is being investigated. There are procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The Manager and other staff spoken with have a sound understanding of safeguarding adults The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 17 procedures. There have not been any safeguarding adults referrals in the last twelve months. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 18 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, 21, 22, and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ quality of life would be enhanced by improvements to the environment in which they live. EVIDENCE: The Hollies is a large building close to Southborough town centre. Accommodation is on 3 floors and these are served by a shaft lift. The home has car parking to the front of the house. The adding of a conservatory on the lower floor and the provision of additional communal space in this area has improved the accommodation in recent years. The furnishings in the communal areas are of generally good standard. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 19 Residents’ safety would be enhanced by the removal of water pipes that have been left projecting from a wall in the dining room. The Director of Care agreed to have this done as soon as possible, with interim safety measures being implemented. The age of the building is reflected in some areas that have damaged plasterwork and/or flaking paintwork. In some places the décor is looking tired and worn, in others it is stained and needs cleaning. Some furniture is damaged and/or worn and needs to be made good or replaced. The Regional South Area Manager said she believes that Regal Care Homes Ltd had agreed funding for the repair, redecoration and refurbishment of parts of the home to commence in the near future, but a plan of work had not yet been finalised. Storage space is very limited and equipment is being stored in a corridor on the lower floor. This area is only used by staff and they have to exercise great care to avoid the obstructions. Some bedrooms are registered for shared occupancy. These bedrooms were in use under the Registered Homes Act 1984 and some would not have been registered under current legislation. Some of these rooms are too small to provide all of the necessary furniture without causing obstruction. The use of shared bedrooms should be reviewed in view of the mental and physical frailty of the residents and their associated behaviours and care needs. Those who share bedrooms are not able to make a positive choice to share with full understanding of the implications. Some bedrooms have an offensive odour, reflective of the occupants’ continence management difficulties. The Director of Care said it is intended to replace some carpets with more hygienic floor covering and a more effective carpet washer has been ordered. Staff must be more diligent in ensuring soiled carpets are cleaned quickly; although the beds in one bedroom had been made and the room tidied, the carpet and bed-frame had not been cleaned as necessary. The Manager undertook to arrange for this to be addressed without delay and to remind staff of their responsibilities in this. This negated the need to issue an Immediate Requirement Notice. As written earlier in this report, when the hairdresser visits each week, it is custom and practice they use a certain bedroom to attend to all their customers. The bedroom’s occupant is not able to use their room at such time and their privacy is potentially compromised. The Manager said funding had been agreed to improve the bathing and sluicing facilities. The home does not have modern sluices/commode washers and some of the bathrooms are too small for the use of lifting aids necessary for residents’ safety. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 20 A support frame around a toilet is not secured, posing a potential hazard for residents. The Director of Care said she will replace this with a frame of safer design. The home has attractive grounds and patio area that resident can enjoy in pleasant weather. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents feel there are usually adequate numbers of staff on duty and that the staff are caring people. The care of residents may be compromised because it is not readily evident that all staff have the skills to meet residents’ needs. EVIDENCE: A survey form completed by a relative included the comment: • “Managers and staff etc always helpful and considerate give good help and assistance in the care of my relative”. There has been a proportionately large turnover of staff in recent months. One consequence of this is that the home is reliant on day staff and agency staff to fill the gaps in the night staffing roster. This has resulted in some staff working excessive numbers of consecutive shifts. Such practices can result in fatigue that compromises the staff member’s competency and may place residents at risk. The Director of Care undertook to ensure that this does not happen again, if needed, agency staff will be used. This negated the need to The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 22 issue an Immediate Requirement Notice. The Director of Care also undertook to ensure that a record is kept of the shifts actually worked by all individuals as required by Regulations. Records seen indicate the home has robust recruitment procedures and the Manager understands the necessity to ensure the home employs only staff that have been properly vetted. The Manager stated that staff do not work in the home without a satisfactory Protection of Vulnerable Adults (POVA) check and do not work unsupervised until a satisfactory Criminal Records Bureau check (CRB) has been received. Staff are required to undertake an induction programme. The Manager explained that where there is not a record of existing staff having completed the induction programme, they will be required to undertake it again and that induction will be more closely monitored. For example it is not readily evident that all new staff have been shown the homes emergency procedures. Agency staff are given an induction when they first work at the home but it is not recorded. It was established at the last inspection that there was ongoing training for staff. The registered Manager then in post maintained a training matrix to monitor individual staff members’ training requirements. Since that person has left, the training matrix has not been updated. Consequently it is difficult to assess the current situation. The Director of Care agreed to undertake a training-needs analysis for every staff member. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 23 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, 37 and 38 The residents benefit from a manager who is experienced, qualified and has a high expectation of the standard of service to be given. EVIDENCE: The Manager has been in post since November 2007 and is expecting the application for her registration as Manager to be submitted in the near future. She has extensive experience in the care sector and has a BSC in Health & Social Welfare, a Diploma in Health & Social Care and a post graduate certificate in Education. Survey forms completed by health professionals included the comments: The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 24 • • “Under new management, have no issues with the home seems to be doing very well” “Current manager seems to be keen to improve care arrangements, manages behaviour and difficult behaviour in clients”. A survey form completed by a staff member included the comment: • “New manager has improved communication system especially issues concerning residents” It is acknowledged that as a result of the time the home was without a permanent Manager, there is a lot of administrative “catch-up” to be done. The management structure of the home has been reviewed and it is intended a Deputy Manager post will be created. Until an appointment is made, additional support will be provided by the Regional South Area Manager and Director of Care. In view of the quantity of work to be done, this support will be vital. There is a sound system of holding and recording service users’ cash, which is regularly checked by the Trust as part of their audit process. Residents and their representatives or relatives are regularly asked for their views. The results of these surveys are made available. The Manager is arranging a residents meeting and a residents/relatives meeting to be held in the near future. The standard of cleanliness in the kitchen and surrounding area is good and, since the last inspection, the home has been awarded a “gold star” for food hygiene by the local borough council. The Director of Care stated that all records of maintenance and safety checks are up to date. These were not inspected on this occasion. The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 26 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 14(2), 15(2), 17 Schedule 3, Schedule 4 Requirement The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review in that service users’ individual plans and records must be kept and be up to date in that they must be consistent and specific in detail of information required. Timescale for action 30/04/08 2. OP9 13(2) All service users must have an accurate care plan by the given timescale, if not sooner, which is thereafter maintained. “The registered person shall 15/03/08 make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that: 1. The hand-written dosages on Medication Administration Record charts must be double signed to be sure they are a true and accurate copy of the prescriber’s intentions. To be completed by the given The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 27 timescale, if not sooner and maintained thereafter. 3. OP10 12(4)(a) “The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users”, in that permission must been obtained from the occupant of the bedroom used for hairdressing and from their representative, for this practice to continue. To be completed by the given timescale if not sooner. 4. OP19 13(4)(a) “The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety” in that unused water pipes that have been left projecting from a wall in the dining room must be removed. To be completed by the given timescale if not sooner. “The registered person shall, having regard to the size of the care home and the numbers and needs of service users keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste” in that all parts of the home, including all bedrooms, must be free of offensive odours. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall, having regard to the size of the care home, the statement of DS0000024029.V358743.R01.S.doc 15/03/08 15/03/08 5. OP26 16(2)(k) 30/04/08 6. OP30 18(1)(c) 30/04/08 The Hollies Rest Home Version 5.2 Page 28 purpose and numbers and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training” in that the home must be able to produce evidence of an induction programme undertaken by all staff, including agency staff working at the home. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training” in that a detailed training analysis must be made for every staff member that includes: 1. Training they have undertaken 2. Training courses booked 3. Details of training provider and any accreditation they may have. A copy of this must be received by CSCI by the given timescale 7. OP30 18(1)(c) 30/04/08 The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 29 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. 2. 3. 4. 5. Refer to Standard OP3 OP9 OP9 OP12 OP15 Good Practice Recommendations It is strongly recommended that all newly admitted service users’ care plans are written in a more timely manner. It is strongly recommended that improved facilities be made available for the storage of medicines. It is strongly recommended that more staff are trained in the administration of medicines It is strongly recommended that activities are provided by staff who are suitably trained to do so and the arrangements for activities are more frequent and varied. It is recommended the options of meals are made known to residents in such a way as they can make a more informed choice and that the portions served are appropriate to individual’s appetites. It is strongly recommended an alternative and appropriate facilities are provided for hairdressing. It is strongly recommended that the proposed redecoration and refurbishment programme is implemented as soon as possible to improve residents’ bedrooms It is strongly recommended the planned provision of additional bathing facilities suitable for service users needs be implemented. It is strongly recommended better storage space for equipment is provided. It is again strongly recommended that the use of bedrooms for shared occupancy should be reviewed. It is strongly recommended improved sluicing facilities are provided in the home. 6. 7. OP19 OP19 8. 9. 10. 11. OP21 OP22 OP23 OP26 The Hollies Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Rest Home DS0000024029.V358743.R01.S.doc Version 5.2 Page 31 - 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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