Inspection on 01/07/08 for Holly Tree Lodge

This is the latest available inspection report for this service, carried out on 1st July 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holly Tree Lodge 22/01/07

Holly Tree Lodge 23/06/06

Holly Tree Lodge 21/07/05

Holly Tree Lodge 12/05/05

Holly Tree Lodge 18/08/04

Holly Tree Lodge 13/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Holly Tree Lodge Sceptone Grove Shafton Barnsley South Yorkshire S72 8NP Lead Inspector Michael O`Neil Key Unannounced Inspection 1st July 2008 09:10 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 Holly Tree Lodge DS0000036220.V366364.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. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Lodge Address Sceptone Grove Shafton Barnsley South Yorkshire S72 8NP 01226 712399 01226 718054 lgeorge@redrosecare.co.uk None Prime Care 4 You Limited 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) Mrs Lynne Marion George Care Home 37 Category(ies) of Dementia - over 65 years of age (37) registration, with number of places Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Dementia - Code DE(E) The maximum number of service users who can be accommodated is: 37 3rd July 2007 2. Date of last inspection Brief Description of the Service: Holly tree Lodge (formerly known as Hawthorne House) is a home for people with dementia. It is on a small residential estate in the village of Shafton. There is a small car parking area. The home is a two-storey building with a lift servicing both floors. There is adequate space to enable service users to move freely and safely around the home. All areas are accessible to people who use wheelchairs. The home has an enclosed garden area accessible from the main lounge. In addition to the communal lounges, there is a visitors’ lounge for service users to see their visitors in private. There are plans to provide beds for people requiring nursing care on the first floor of the home. This floor is currently being totally refurbished. The service is hoping to have these beds registered by the CSCI in August 2008. The manager confirmed that the weekly fee from 1st July 2008 was £380.50. Additional charges included hairdressing and private chiropody. Holly Tree Lodge DS0000036220.V366364.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 2 star. This means that the people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Mike O’Neil, regulation inspector. The CSCI inspector visited Holly Tree Lodge for a total of 6 hours. Lynne George is the manager and was present during the visit. Prior to this visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of this report. Questionnaires, regarding the quality of the care and support provided, were sent to people staying in the home, their relatives and any professionals involved in peoples care. We received three questionnaires from relatives and three from staff. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to four staff, two visiting health professional, seven people who live at Holly Tree Lodge and receive further feedback from two relatives. We checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in July 2007. The progress made has been reported on under the relevant standard in this report. We wish to thank the people living in the home, staff, visiting professionals and relatives for their time, friendliness and co-operation throughout the inspection process. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 6 What the service does well: Staff at the home were regularly consulting with and requesting reviews from health professionals when the person’s needs were changing. People looked clean, well dressed and had received a good level of personal care. People said “The staff are very obliging” “The staff are wonderful” Relatives said “The care is good” “The staff show understanding.” Visiting professionals felt the care delivered was of a good standard and had improved over the last year. They added that they had every confidence in the manager and staff to provide a good service and said that staff liaise well with them. They felt that the care needs of people were well managed and gave examples of where peoples physical and mental well being had improved since they were admitted to Holly Tree Lodge. The mealtime experience for people in the home was very positive. Tables were set nicely with cloths, condiments and matching crockery. Staff were supporting people with their meal in a polite and discreet way. Some people were having a glass of beer with their meal, which they said they really enjoyed. The home was clean and tidy and no unpleasant odours were noticeable. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. Staff, people, relatives and visiting professionals spoke highly of the manager and said she was very approachable. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Holly Tree Lodge DS0000036220.V366364.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 Holly Tree Lodge DS0000036220.V366364.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): Standards 1,2 and 3.Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People and their representatives have the information needed to choose a home, which will meet their needs. People were individually assessed prior to admission to ensure their needs could and would be met. EVIDENCE: Copies of the Statement of Purpose were available for people and their families. The Statement of Purpose covered all the main areas required by regulation and had been recently updated by the manager. The manager confirmed that each person or their family is provided with a statement of terms and conditions prior to moving to the home. This sets out Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 10 in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the person. We checked a contract of a person who had just moved into Holly Tree Lodge and all the information required was included in the contract. Three peoples files were checked and each contained a copy of their full needs assessments. Prior to admission taking place, professionals and staff from the home assessed people. Evidence was seen that the staff at the home were regularly consulting with and requesting reviews from health professionals when the person’s needs were changing. Holly Tree Lodge DS0000036220.V366364.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): Standards 7, 8, 9 and 10. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People’s health is monitored and arrangements for dealing with health issues were met with support from health professionals. People were treated with respect and said they were satisfied with the care they received. Medication policies and procedures were well managed ensuring the safe administration of medication. EVIDENCE: Three peoples care plans were checked. The peoples care plans checked were good in that they contained details about the person’s biography, personality and their preferences and choices. Previous requirements made at the last Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 12 inspection had been addressed. The plans were being regularly reviewed and the changes in people’s health were being observed and recorded. Overall though there seemed to have been a significant improvement in the standard of the care plans and the recordings made by staff. People looked clean, well dressed and had received a good level of personal care. People said “The staff are very obliging” “The staff are wonderful” Relatives said “The care is good” “The staff show understanding.” Visiting professionals felt the care delivered was of a good standard and had improved over the last year. They added that they had every confidence in the manager and staff to provide a good service and said that staff liaise well with them. They felt that the care needs of people were well managed and gave examples of where people’s physical and mental well being had improved since they were admitted to Holly Tree Lodge. Medicines were securely stored in locked trolleys within locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. A requirement made at the previous inspection had been met. Staff said they had received medication training. We saw certificates of this training. Staff were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. People were able to make choices about daily living and be involved in some social activities. Meals served at the home were of a good quality and offered choice to ensure people receive a balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home and in the homes gardens. Relatives said they were able to visit at any time and were made to feel very welcome. Since the last inspection a new clock, which also displays the day and date had been bought and displayed in the lounge. The menu notice board was Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 14 completed with the date and menu for the day. This type of information will help people with orientation. People and relatives said that there were some activities planned such as trips to local beauty spots and entertainers visiting the home. People, relatives and professional visitors said the frequency of activities had improved since the last CSCI visit. We saw that some people welcomed the opportunity to undertake simple activities and talk to staff or other people in the home. Staff seemed much more relaxed and able to sit and talk to people than on previous visits to Holly Tree Lodge. People also enjoyed watching a 1960’s musical on DVD in the afternoon. A nice touch was that people were given an ice cream whilst they watched the movie which added to the ambience of the occasion. The mealtime experience for people in the home was very positive. Tables were set nicely with cloths, condiments and matching crockery. Staff were supporting people with their meal in a polite and discreet way. Some people were having a glass of beer with their meal, which they said they really enjoyed. People said “We always get a good meal” “The food is very good”. The cook was aware of peoples special dietary needs and said that people were asked each morning what they wanted for lunch. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced would be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their representatives had been provided with a copy of the homes complaints procedure. The policy contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People and relatives said they had no concerns about the home, staff or service provided. They said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 16 Regarding safeguarding adults, the safeguarding policies and procedures were available to the staff. Staff had undertaken Safeguarding Adults training, and the manager was able to evidence this by producing the training records. (Previous requirement met) Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home was clean, pleasant and hygienic although some areas of the home are in need of redecorating and refurbishing. EVIDENCE: The home was clean and tidy and no unpleasant odours were noticeable. Lounge and dining areas were domestically furnished to a good standard. Since the last inspection there has been a continued refurbishment of the home. There are plans to provide beds for people requiring nursing care on the first floor of the home. This floor is currently being totally refurbished. . Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 18 The majority of the home is now bright and cheerful. Touches have been added to make Holly Tree Lodge feel more homely. People and visitors said they were really pleased with the cleanliness and the continued refurbishment of the home. Other areas of the home however are in need of refurbishment and redecoration. Some bedrooms are being redecorated and new carpets laid. The refurbished rooms are bright and airy. This rolling programme of bedroom refurbishment should continue. There is still work to be completed in the garden areas of the home. People were still accessing the enclosed garden, however, and sitting out on the furniture provided. In view of the above two points the requirement relating to the environment has been carried forward. Overall however the service must be commended on the continued improvement and transformation of the homes environment. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers and in the main recruitment procedures promoted the protection of people. People receive care from a well-trained staff team. EVIDENCE: The majority of people, staff and relatives said staffing levels were adequate. People said that staff were always around when they needed them. Some relatives and staff did raise some concerns over staffing levels. The manager confirmed that staffing levels were adequate. Currently the home is not at full occupancy and has only 16 occupied beds. The manager confirmed that staffing levels would increase again as more people were admitted to the home and added that she was monitoring the staffing situation closely. Three staff files were checked. The recruitment information obtained for the staff was in the main sufficient to adequately protect the welfare of people who lived at the home. One file did not contain a reference from the employee’s last employer but did contain another reference an enhanced Criminal Record Bureau (CRB) and Protection Of Vulnerable Adults (POVA) check. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 20 The other two files checked contained a range of information including two references and a declaration of health and identification. The staff had undertaken a CRB at the enhanced level. The manager confirmed that all other staff working at the home had completed enhanced CRB/POVA checks. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. We found that the staff were very enthusiastic to improve the service further. Staff were able to talk about the various training courses that they had attended. Development and training records were checked these records showed when staff had completed mandatory training and refresher training. The amount of training provided for staff has improved since the last inspection. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 21 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): Standards 31,33,35,and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The procedures and ethos of the home ensure that the home is run in the best interests of people who use the service. In the main the homes procedures promote the health, safety and welfare of people who use the service and the staff. EVIDENCE: The manager, Lynne, has many years experience within the caring profession and had obtained the Registered Managers Award. She is committed to Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 22 ensuring that people staying in the home were consistently well cared for, safe and happy. Staff, people, relatives and visiting professionals spoke highly of the manager and said she was very approachable. The home had a comprehensive quality assurance system. There was evidence of internal auditing of the homes environment, services and records. Staff meetings were held and minutes of these meetings were seen. The responsible individual visited the home on a regular basis, a report was written following the visits. People who use the service and their families met with the management of the home. These quality assurance systems will help to ensure that the service is operating in the best interest of the people who live there. The home handles money on behalf of some people. Account sheets were kept and receipts were seen for all transactions. However some people’s financial interests with larger amounts of money in the bank were not fully safeguarded. Bank statements were now being held at the home to provide evidence that people’s monies had actually been banked. These monies were also accruing interest. However the interest accrued had not been apportioned to individuals. The service had developed a fire risk assessment which had been reviewed in November 2007.It was not adequate however because it had not been fully completed. The manager gave assurances that the assessment would be fully completed by the end of the week. Within the actual incomplete fire risk assessment there were no issues requiring attention. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving this statutory training. At the time of the visit fire exits were clear and hazardous products were safely stored in the home. This will promote the safety and welfare of the people. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23 Requirement All areas of the home used by people must be well maintained, of sound construction, kept in a good state of repair externally and internally and must be well decorated. This requirement carried forward from July 2007. Good progress made since that date to achieving it. The home must obtain all relevant information and documents before new employees commence work. Increased procedures must be put in place to ensure that residents’ financial interests are safeguarded. The fire risk assessment must be fully completed so that staff are clear of all fire procedures /precautions within the service. Timescale for action 01/01/09 2. OP29 19 01/08/08 3. OP35 16,17 01/10/08 4. OP38 23 01/08/08 Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 25 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 OP27 Good Practice Recommendations The manager should continue to monitor the staffing situation closely and increase levels dependant on people’s dependency levels. Holly Tree Lodge DS0000036220.V366364.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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