CARE HOMES FOR OLDER PEOPLE
Holly Lodge Gaskell Road Bucknall Stoke-on-Trent Staffordshire ST2 9DW Lead Inspector
Rachel Davis Unannounced Inspection 1 February 2006 11:30 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 Lodge DS0000008238.V281031.R01.S.doc Version 5.1 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 Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Holly Lodge Address Gaskell Road Bucknall Stoke-on-Trent Staffordshire ST2 9DW 01782 303952 01782 302187 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 Shirley Mary Harrison Mr George Littleton Mrs Shirley Mary Harrison Care Home 12 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (12) Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Holly Lodge is a residential care home offering 12 places; four of these may be for service users with mental frailty. At the time of this inspection there was one vacancy. Holly Lodge is a two-storey purpose built establishment; it is situated in a residential area of Bucknall, affording service users the opportunity of maintaining links with the neighbouring community. It is well placed for the local amenities and the home has the facility of a main bus route. Both the exterior and interior of the property are very well maintained, it is exceptionally clean and the décor is set to a very high standard. The service users are offered easy access to all areas of the home by the use of grab rails and a lift. All bedrooms meet the required sizes set out by the national minimum standards and are equipped with suitable fixtures and fittings. The bathrooms and toilets are well located and offer appropriate equipment and facilities. Communal areas are spacious and comfortable; the lounge area has doors opening onto a large conservatory overlooking a mature and well-kept garden. Patio areas with seating are available and easily accessed. Satisfactory car parking is available. Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over 2.5 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. This visit only covered a small number of the national minimum standards, to ascertain a full picture this report should be read alongside the unannounced inspection held on 14th June 2005. The inspection included an examination of records, indirect observation, discussions with service users, the registered providers and staff. The home continues to exceed the majority of national minimum standards; no requirements were made as a result of this visit. What the service does well:
Holly Lodge continues to be highly respected within the community and surrounding areas. The management and all the staff within the home contribute to the high standard of service provided. Their commitment to the provision of a quality service for their service users is commendable. One service users comment verified the way service users feel who reside there. “ Nowhere else can touch it, it is a lovely home I can’t ask for more.” The management team work in partnership with other professional bodies to ensure the best outcome for the service users. The management are transparent and open and always welcome discussions around continually taking their service forward. The home operates a service user centred approach and demonstrates a very good understanding of service users care needs. Assessment and care planning are of a high standard; the risk assessments are well managed. Service user comments include: “ I like everything here.”
Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 6 “ It is a very very nice home.” “ I am very settled and very comfortable.” “There is a good atmosphere here, the staff are friendly, I get on well with them all.” The home takes pride in supporting staff and ensuring staffs individual needs are identified and met accordingly. Care staff felt well supported and comments include: “ The management are very flexible with us.” “ We just need to ask and things will be actioned.” “ Training is always available.” “It is friendly, with good people, informal, we get good support.” Communication and information exchange with all relevant parties is excellent. The home ensures staff are not employed without full employment checks therefore confirming they are suitable people to work with service users. All newly appointed staff undergo an excellent induction programme to promote good practice, confidence and understanding in the service delivery, and the homes policies and procedures. There is a commitment to NVQ training for staff, over 60 of care workers have either achieved the award or are working towards it. The home is kept exceptionally clean and is a credit to all the staff. Policies and procedures are continually updated. What has improved since the last inspection?
No requirements were made on this, or at the last inspection. The manager has implemented both the recommendations made by the Commission from Junes’ inspection. The Statement of Purpose and Service User Guide have been updated and exceed the national minimum standards. The deputy manager continues to review the risk assessments as and when a new situation arises; this ensures the safety of staff and service users is continually improved upon and maintained.
Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 7 The home is commencing the Investors in People Award in the near future. The exterior of the property has been repainted, a rolling programme for internal decoration continues. 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. Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 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 Lodge DS0000008238.V281031.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Holly Lodge delivers a flexible, reliable, consistent and focussed service. All information offered ensures that service users and prospective service users can make an informed choice about the home. EVIDENCE: The homes’ statement of purpose and service user guide offers current and prospective service users and significant others the opportunity to make an informed choice about the services provided and whether the home can meet their needs. Information within these documents exceeds the national minimum standards. Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 10. The assessed health and personal care needs of service users are well documented and were being met, very good standards of care continue. Service users are treated with the utmost respect and their wishes regarding privacy and dignity are upheld. EVIDENCE: Following the inspection of records and discussion with the deputy manager, staff and service users it was revealed that service users received a wide range of health care services according to their need. One service user revealed: “You only have to mention the GP and he is here.” Staff confirmed that their relationships with visiting professionals were very good. “ We always get a good response.” Service users feel they are treated with respect, their comments include:
Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 11 “ I am well looked after” “We choose all our own meals you know.” “Lovely home you could not ask for more.” Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. There are ranges of activities open to the service users to meet their needs and family and friends are encouraged to visit. Service users were supported and enabled to exercise their right to make their own decisions and choices. EVIDENCE: Holly Lodge ensures that the service users differing expectations and preferences to lifestyle are met. Some service users choose to become actively involved with the running of the home; others catch the bus regularly and go into town, comments included: “We go out into the community whenever we please.” “We do as we please.” One service user had gone out with their family for the afternoon and to meet their needs lunch had been prepared separately and at an earlier time, one other service user was off to the local hairdressers, others chose to spend time quietly in their rooms, others played bingo with the staff. A relaxed, informal and diverse impression was apparent. Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 13 Comments made by visitors revealed the following: “ We are always made welcome.” “Everything is very nice as usual.” “Very pleasant surroundings and a warm friendly welcome.” Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Service users are fully aware of what to do and who to speak with should they require. They confirmed that they are always listened to by the home. EVIDENCE: The home had a comprehensive complaints procedure and a copy is located within the home for the benefit of relatives and visitors alike. Service users are provided with a copy of the complaints procedure within the service user guide. The Commission has not received any complaints about the home, and the home had not received any complaints either. An open transparent and inclusive view is taken service users said if they have something to say we “just say it.” Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30. Staffing numbers and skill mix are appropriate to the needs of the service users. Mandatory and specialist training is always delivered when required. There is on-going commitment to staff training and the National Vocational Qualification achievements were a credit to the management and the staff in the home. EVIDENCE: All staff within the home have a raft of meaningful training, this ensures an ameliorating service is continually offered to the service users. Since the last visit all staff have undergone the refresher moving and handling course, fire training and evacuation procedures, recognition of abuse, basic food hygiene have been completed as required. All staff will soon commence infection control, medication training has been re introduced to remind and update the staff. The manager is hoping to facilitate another training course in both dementia awareness and behaviours that challenge. NVQ training is high priority for the management and staff working at Holly Lodge, 3 staff have NVQ2, one of these staff also has NVQ3 and one other has recently started level 3. One other member of staff is presently doing NVQ2 and another will be starting the course on 06/02/06. Four staff do not have the qualification. Regulation states that 50 of the workforce must be trained; Holly Lodge just exceeds this level.
Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35. Good robust recording systems are in place within the home. Structured and methodical processes ensure procedures are completed safely and are well documented. EVIDENCE: The health, safety and welfare of staff and service users are as far as reasonably practicable protected. The manager ensures the service users control their own money except where they choose not to. The records of financial involvement were scrutinised on this occasion. Where the money of an individual was handled, appropriate recording and receipts were kept. All monies checked were as recorded. The home should consider purchasing a receipt book to further strengthen their procedures.
Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 18 Both the registered manager and the deputy manger are committed to ensuring that the best quality of care is offered to each individual, this was another very positive inspection. Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 19 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 4 X X 4 X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 4 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 4 28 4 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 OP35 Good Practice Recommendations The registered manager should consider strengthening their financial transaction records by introducing a receipt book. Holly Lodge DS0000008238.V281031.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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