Inspection on 10/07/07 for Holly Lodge

This inspection was carried out on 10th July 2007.

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 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

Holly Lodge 26/06/06

Holly Lodge 20/02/06

Holly Lodge 10/08/05

Holly Lodge 23/02/05

Holly Lodge 16/08/04

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Insight - Eastchurch

Southfields

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Dovedale Court

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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 Christine Lawrence Unannounced Inspection 10 July 2007 09:50 Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 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 DS0000023961.V343237.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 Adults 18-65. 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 DS0000023961.V343237.R01.S.doc Version 5.2 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 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) theavenuestrust.co.uk The Avenues Trust Limited Mr Wayne Lloyd Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26 June 2006 Brief Description of the Service: Holly Lodge is a small residential care home providing care and support to four residents with learning disabilities. The Avenues Trust Ltd is the provider and there are other properties also owned by the Trust on the same site. The bungalow is situated in a rural area near to the village of Hildenborough; local shops and bus stops are approximately a mile away. All the rooms are single accommodation. There is a lounge and separate dining room. There is a front and rear garden which are satisfactorily maintained. Car parking spaces are available. The home’s current of fees are £1,176.55. Information about the home, including the previous inspection report from the Commission for Social Care Inspection, would be made available on request. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit started at 09.50 and finished at 14.45. I looked at various records in the home and also used information sent to the commission by the registered manager, Wayne Lloyd before the visit. This was in the form of the Annual Quality Assurance Assessment (AQAA). Information from the previous inspection was also referred to. I spoke with several of the residents and was invited to see some bedrooms. A tour of the parts of the rest of the building was undertaken. I made observations of staff interacting with and supporting residents. Staff chatted informally with me and I had discussions with the group manager who was visiting the home at the time and the senior carer who was in charge at the time of the visit. What the service does well: 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 Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 6 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 Outcomes Statutory Requirements Identified During the Inspection Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ individual aspirations and needs will be assessed. EVIDENCE: Two individual records were looked at for this inspection. Although there have been no new admissions for a while, it is clear that new residents will only be admitted after a detailed assessment process which includes getting information from the placing authority’s representative. The assessment information is used to compile a care plan. The format being used in the home is based on person centred planning and focuses on an individual’s wishes as well as their needs. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their changing needs will be noted in their individual plans and that they will be supported to make decisions and take risks to enable as independent lifestyle as possible. EVIDENCE: Two individual records were looked at for this inspection. There is a lot of information on each person and therefore it is separated out by an index. A broad range of subjects is assessed (Holistic Profile) including communication and choice, weekly plans, behaviour, finance spiritual and cultural needs. Information is used to identify any personal goal that the staff are trying to support the resident to achieve (Personal Planning Book). Specialist advice is sought for particular needs and the home also operates a key worker/co-key worker system. Communication requirements are noted. The plans are regularly reviewed and this includes the residents and their representatives where appropriate. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 9 Each resident had a financial section in their individual record and examples were noted of people being enabled to be as independent as possible. Each person has a risk evaluation/intervention section which is individual and focuses on benefits to the individual with steps to reduce any risk rather than simply avoiding an activity that has a degree of risk. There are clear guidelines for staff to enable an activity to take place and this links into guidance about any daily routine. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities and involvement in the local community, as well as support for personal relationships will be provided for residents. They will benefit from being offered a healthy diet and a sociable setting for mealtimes. EVIDENCE: The records seen for this visit, as well as information provided by staff, the manager and residents all reflect that residents are enabled and encouraged to take part in appropriate activities both within and outside the home. This includes household activities and responsibilities (which varies according to residents’ individual abilities), gardening, using local day opportunities provision, and all sorts of local amenities such as shops, library, pubs leisure centres and restaurants/cafes. There were examples noted of holidays (including two people going to Spain this year), days out, special barbeques and day trips to France. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 11 Relationships are supported and examples were noted of staff facilitating contact through the use of supporting people to use the phone, making residents’ visitors welcome, helping with relatives visiting the home and inviting relatives to social occasions. There are daily plans for each person which contain clear guidance for staff about routines, preferences for personal care and any particular support needs for eating. On the day of the site visit one resident was at his day service and the other three went out for lunch. I was informed that residents’ preferences are known and any planned meal reflects residents’ choices. One resident said he likes to help with food and likes cooking. The dining room allows for everyone to sit together for meals. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s policies and procedures regarding medication and their physical and emotional needs will be responded to. EVIDENCE: There is guidance for staff about how an individual prefers and requires personal care to be provided. Same gender care is provided whenever possible. The daily records show that people get up and go to bed when they wish although mostly people have a routine that they like. There were examples of residents choosing whether or not to go to a day activity and other examples of having control over their lives. Independence is considered an important part of the support provided at the home and the manager indicated in his written information (AQAA) that the home has progressed with the ethos of encouraging people to do as much as possible for themselves rather than staff doing things for residents. Healthcare needs are clearly assessed and recorded within the individual care plans and there are Health Action Plans in place for each person which are reviewed monthly. Health care professionals are accessed regularly or as Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 13 required. Residents have the opportunity for health screening such as Well Man Clinics. Medication is appropriately stored and administered. Staff who give out medication have received training. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are aware of their responsibilities for protecting residents from abuse and residents’ views are listened to and acted on. EVIDENCE: A copy of the complaints procedure is on display and there have been three complaints in the last 12 months. These were satisfactorily investigated. Staff have received training regarding safeguarding adults and the organization has a range of relevant policies and procedures. There are plans to make the complaints procedure more relevant or tailored to individual residents. Staff spoken to were clear about their responsibilities towards the residents and confirmed that they were aware of the procedures for whistle blowing. There have been three safeguarding adults issues in the last twelve months all reported by the home. The information made available does indicate that the home is open about any issues of concern. Staff have received training with regard to adult protection. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable and safe for the residents. EVIDENCE: The building is suitable for its stated purpose. The house is bright and cheerful and satisfactorily maintained. The manager and staff confirmed that redecoration and replacement of fittings is on going. There is an attractive garden to the rear and a garden area to the front of the building. The kitchen has been refitted and redecorated and there are just a few finishing touches. The laundry is small but adequate for the needs of the residents. It has recently been refurbished. There is no space for a hand washbasin but there is a plan to fit an alcohol gel dispenser to ensure the opportunity for hand washing before leaving the laundry area. The home was clean and fresh on the day of this visit. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sound recruitment procedures and training provided to staff will have a beneficial impact on residents. EVIDENCE: The staff on duty at the time of the inspection were knowledgeable about the residents and their individual needs such as communication. A Cultural Needs Assessment has been completed for each person which helps staff to understand any particular need relating to the individual such as their religion. I observed members of staff to be interested in the people they were supporting and good communicators. The manager provided information within the AQAA that two people have achieved national vocational qualifications (NVQs) level 2 and two people are working towards this. The home currently has to use agency and bank staff as there are vacancies but the manager said in the AQAA (and this was confirmed by staff in the home) that they try to be consistent in who works at the home, including ensuring to try and reduce the risk of lack of consistency. The organization is committed to recruiting more permanent staff. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 17 The manager and staff confirmed that the process of recruiting new staff includes a criminal records bureau check, two written references, application forms and interviews. Staff have written terms and conditions of employment and are all given a copy of the General Social Care Council’s code of practice. There is a programme of training, including induction training (in keeping with the Common Induction Standards from Skills for Care) which covers a range of subjects relating to the care of people with learning disabilities. Makaton training is provided as is training regarding valuing diversity. Staff have also been provided with training course relating to managing difficult behaviour. Most staff have completed this and more is planned. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 18 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and their health and safety is promoted and protected EVIDENCE: The manager has almost completed his qualification course. He is experienced and keeps up to date with periodic training. The organization seeks the opinions of residents and their representatives about the home. They carry out visits under Regulation 26 ie they visit the home regularly to undertake their own checks on quality. Policies and procedures are regularly reviewed. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 19 The training programme covers a range of aspects of health and safety such as first aid, food hygiene, manual handling and fire safety. The fire safety checks are appropriately carried out. The organization has relevant and appropriate policies and procedures and a spot check on maintenance and service contracts showed that these were satisfactory and up to date. Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 21 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. 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. Refer to Standard Good Practice Recommendations Holly Lodge DS0000023961.V343237.R01.S.doc Version 5.2 Page 22 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. 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