Inspection on 10/08/05 for Holly Lodge

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Lodge 10/07/07

Holly Lodge 26/06/06

Holly Lodge 20/02/06

Holly Lodge 23/02/05

Holly Lodge 16/08/04

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

CARE HOME ADULTS 18-65 Holly Lodge Alexandra Drive Vines Lane Hildenborough Kent TN11 9LT Lead Inspector Paul Stibbons Unannounced 10 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holly Lodge Address Alexandra Drive Vines Lane Hildenborough Kent TN11 9LT 01732 834225 01732 834225 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Avenues Trust Ltd CRH Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23 February 2005 Brief Description of the Service: Holly Lodge is a residential care home providing a service to a maximum of four service users from 18 to 65 years of age. The service users have learning difficulties and require a specialist setting. The bungalow is situated in a rural area near to the village of Hildenborough; local shops and bus stops are approximately a mile away. The accomodation comprises of four single bedrooms for service users, a combined staff office/staff sleep in room, kitchen, lounge, dining room, bathroom and a utility room. There is a front and rear garden which are well maintained. Avenues Trust Ltd owns the property and other properties also owned by the Trust are on the same site. The environment is homely and service users are supported to take part in activities to maintain and increase their skills and a variety of leisure pursuits if they wish. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory Inspector Paul Stibbons carried out this unannounced inspection. The home’s manager was not available at the time of inspection and the inspector would like to thank the shift leader Benjamin Timson for his assistance. A tour of the building was undertaken and a number of documents were inspected. One of the service users was attending day services but the inspector had the opportunity to speak with two service users and two members of staff What the service does well: What has improved since the last inspection? Since the last inspection the lounge furniture has been replaced with new chairs and a settee, also there are new curtains for the patio door. The staff team has started to redecorate some areas of the home to the service users’ choice. The home’s manager has applied for registration to the Commission. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 Prospective service users are provided with the information they require to make an informed decision before moving into the home. Comprehensive assessments ensure the home is able to meet individual needs. EVIDENCE: The home’s service user guides and statement of purpose provide clear and accessible information to prospective service users and are in written, pictorial and audio tape format. A copy of the most recent inspection report is on display for service users and their relatives. Two service user files were inspected and both contained comprehensive assessments detailing individual needs. Staff training records evidenced training for staff to meet client needs within their role and one service user spoken with confirmed his satisfaction with staff and the home. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 The home ensures through person centred planning, in consultation with service users and their keyworker, that individuals’ changing needs and personal goals are reflected in their care plans. The home’s policies and procedures ensure confidentiality of information. EVIDENCE: Two service user care plans were viewed and these contained support needs and daily/weekly activities, risk assessments, goal setting and financial information. Robust procedures are in place to record financial expenditure and a member of staff was able to produce receipts and cash that balanced on checking. When asked about the amount of cash being held for one individual (in excess of £100) the member of staff explained it was for a planned shopping trip with the service user. It was stated that service users had been consulted on the choice of décor for their individual rooms and two service users confirmed this. Service users are involved in menu planning and one service user was observed assisting in this task. All service user records were secure in the home’s office. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 17 Service users participate in a range of activities within the home and externally in the community to meet their occupational and leisure needs. Family contact is encouraged by staff to maintain service user relationships. Participation in menu planning is encouraged to ensure a healthy and varied diet that includes service user choices. EVIDENCE: Service users are encouraged to participate in activities of their choice within the home and are supported in accessing facilities in the community. One service user with a visual impairment was involved in building a sensory board of different textures with support from staff. The Inspector spoke with one service user who expressed his interest in heavy machinery; the bedroom of this service user had many books and photographs of outings to support his interests. Works of art from craft sessions were on display within the home. At the time of inspection one service user was attending a resource in the community for the day Photographs of outings and holidays were evident in service users’ bedrooms. Service users are supported in maintaining family contacts, these occasions are recorded and family photographs were evident Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 11 within the home. The inspector was present at lunchtime and observed a service user assisting in the preparation and serving of the meal. Staff sat with service users for lunch and good social interaction was observed. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Service user healthcare needs are assessed and recognised and they are supported in accessing healthcare facilities locally with prompt referral to an appropriate specialist. Service users are unable to administer their own medication and are protected by support from staff whose competence has been assessed through medication training. EVIDENCE: Service users care plans that were viewed contained comprehensive assessments of needs and evidence of referral to healthcare professionals. Service user body weight is monitored and recorded on a regular basis. The home’s medication is stored in a purpose built cabinet within the manager’s office. The room temperature at the time of inspection was 22c evidenced by a thermometer on the wall. A photograph for positive identification preceded each service users’ medication, however, it was noted that information required updating, as it did not reflect current medication prescribed. Creams and ointments were clearly marked for service users but require dating when opened to ensure disposal complies with directions. PRN protocols were in place and gave clear directions, they were signed and authorised by the prescribing GP. The returns book and MARS sheets were inspected and were found to be accurately completed. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Staff training on adult protection issues and policies and procedures within the home ensure, as far as possible, that service users are protected from abuse, neglect and self-harm. EVIDENCE: Training files for staff members evidenced training on adult protection. Staff was observed to be alert to one service user’s increasing irritability during the inspection and defused the situation in a professional manner. CSCI have received notification of a recent allegation made under the ‘whistle blowing’ policy and the resultant action that is being taken. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 24, 25, 26, 27, The service users live in a homely and comfortable environment where they are consulted on choice of décor of the home. All areas of the home are fully furnished and the facilities meet the needs of the service users. Some areas of the home would benefit from some maintenance work. EVIDENCE: The home has benefited from the purchase of new lounge furniture and curtains for the patio window, a drawer unit was observed to have a broken drawer and this needs replacing or repaired. The home has been undergoing redecoration and service users have been consulted on the choice of décor. Individual rooms are decorated to the service users’ wishes and personal possessions are displayed to reflect their interests and lifestyles. The kitchen units are looking worn and a plinth beneath the cooker is broken, one of the units had a door removed to enable the fitting of a dishwasher and this needs addressing. Due to previous water damage the skirting in one area has been removed, this does not enable a seal between wall and floor to maintain hygienic conditions. The kitchen doorframe has only been half painted. A member of staff informed me that the staff team have done the decorating and whilst their dedication and commitment to the service is to be commended a Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 15 dedicated maintenance team should be available for these tasks. The bathroom floor and skirting is stained and damaged and requires replacing. The home has a utility room that is away from food and preparation areas with appropriate laundry facilities and procedures. On the day of the inspection the home was clean and free from offensive odours. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 Service users are supported by an effective and competent staff team and benefit from clarity of staff roles and responsibilities. EVIDENCE: Discussion with staff evidenced there was clear knowledge of the aims and values of the service and their roles and responsibilities were understood. The service users know what staff to expect on duty by a prominent display of photographs of staff team. Certificates were seen in the staff training file for core courses to enable staff to effectively fulfil their roles. Currently two members of staff holds NVQ level 2 or higher, one member of staff is currently working towards this qualification and two members of staff are on the waiting list. The home manager has applied to the Commission for registration. Personnel files could not be viewed as the home’s manager was not present and they hold the keys for access. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41 Service users benefit from a clear sense of direction and leadership where staff understands their roles and responsibilities within the service. Staff training and policies and procedures within the home ensure the confidentiality of personal information. EVIDENCE: Two members of staff were spoken with and expressed a commitment to the quality of service within the home. Both stated they had the utmost respect for the home’s manager and felt there was openness and transparency on all issues concerning the home. Records that were viewed were up to date and legible and secure with access to authorised personnel only. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Lodge Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 x x H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement A record is maintained for current medication for each service user. Ointments and creams etc are to be dated when opening to clarify use by date. Make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. In this context attention to the bathroom and kitchen flooring and skirting. Timescale for action By 25 September 2005 Action plan by 25 October 2005 2. YA24 16(2)(j) 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 YA24 Good Practice Recommendations The broken drawer unit in the lounge needs repairing or replacing and a planned maintenance programme to repair or replace kitchen units. Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holly Lodge H56-H06 S23961 Holly Lodge V242039 100805 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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