Inspection on 02/03/06 for Holly Lodge

This inspection was carried out on 2nd March 2006.

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

Other inspections for this house

Holly Lodge 03/04/07

Holly Lodge 13/11/06

Holly Lodge 05/09/05

Holly Lodge 03/03/05

Holly Lodge 08/09/04

Holly Lodge 04/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Holly Lodge 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA Lead Inspector Mike Kirton Unannounced Inspection 09:00 2 March 2006 nd 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 DS0000024971.V285324.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 DS0000024971.V285324.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holly Lodge Address 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA 01384 373306 01384 378160 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) Mr Mohammed Iftikhar Ali Mrs Paula Hubble Care Home 21 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (2), Old age, not of places falling within any other category (19) Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 2 DE, 2 MD and up to 19 OP Date of last inspection Brief Description of the Service: Holly Lodge is a residential home registered to provide 24-hour care for 21 people over the age of 65. It is located on a residential road just off the main Hagley Road in Oldswinford near to the church. It is accessible by public transport and close to local shops and public houses. The home has 19 single rooms and 1 double room, 2 lounges and a conservatory. There is a well-maintained garden to the front and rear and parking facilities at the side. Accommodation is provided over 3 floors accessible via passenger lift or staircase. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours and included interviews with the registered manager and informal discussions with the service users and staff members on duty. Additionally 2 service user files and records relating to health and safety and medication were examined. 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. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 6 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 DS0000024971.V285324.R01.S.doc Version 5.1 Page 7 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 5th September 2005. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 8 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): 9, 10 The procedures for ordering and administrating medication have improved however further checks are required to prevent the risk of infection or cross contamination. EVIDENCE: Standards 7 and 8 were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 5th September 2005. The home maintains a copy of all prescriptions and records all medication received and returned to the pharmacy. Administration records were complete with no gaps seen. All tablets (except for those prescribed for only when needed) are kept in sealed cassettes. Creams prescribed for other residents were found in another’s bedroom. Eye drops with a 28 day use by period had not been dated when opened and pain killers for a resident no longer at Holly Lodge were kept. All personal and medical care is carried out in private. Staff were seen to knock before entering rooms and treated residents with respect. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 9 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): 13, 14, 15 The manager and staff ensure that visitors are always made to feel welcome at Holly Lodge. A good standard of choice and quality of meals are maintained. EVIDENCE: Standard 12 was not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 5th September 2005. The homes policy allows for visitors to be seen at any reasonable time (avoiding meals times if possible) or with prior agreement. They can be received either in one of the communal areas or the privacy of their own room. Bedrooms can be furnished with their own personal possessions (subject to health and safety requirements). Details of advocacy services are available and residents are able to manage their own finances and have access to personal records if requested. The menu board in reception clearly displays the choices available for the day including 2 options of a cooked lunch. Feedback is being sought as part of the homes quality assurance programme however all comments received praised the standard of cooking in the home. Personal preferences and dietary requirements are recorded and hot and cold drinks are available at all times. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 5th September 2005. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 11 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): 19, 26 Holly Lodge has a homely, relaxed, and comfortable atmosphere, benefiting from several lounge areas for residents to choose from in addition to their own room. The home was found to be clean and tidy throughout and generally well decorated and maintained. EVIDENCE: A tour of the buildings took place including all communal areas, laundry, kitchen and several residents’ bedrooms. Several areas continue to require further refurbishment in particular the 2 toilets on the ground floor, dining room furniture, and carpets on the stairs and landing. These should all be included in the maintenance and renewal plan. Improvements have continued including new carpets in the hallway, fitting of a new hand washing facility and painting the laundry room. During the inspection a new store cupboard was being built which also removed the risk of anyone falling down a step in the corridor. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 12 Further work is required in the laundry including the fitting of a new floor. Appropriate safety procedures were being followed to reduce the risk of cross contamination. Facilities are currently suitable for the needs of the residents. The kitchen was also well maintained and all food was found to be stored correctly. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 5th September 2005. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 14 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): 31, 33, 35, 38 The home benefits from having a good manager in place with many years experience and training. Plans are in place to improve the systems of quality assurance and appropriate health and safety measures are being taken. EVIDENCE: Paula Hubble has worked at Holly Lodge for the last 17 years and for the last 6 as registered manager. She has the NVQ level 4 qualification in Management and Care and has continued to update her training. The home has a quality assurance procedure in place based upon a Hereford and Worcestershire policy. This system now requires updating in line with the current standards. Forms have been developed by the home and questionnaires prepared to obtain feedback from residents, visitors, and other stakeholders i.e. GP and Social Worker. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 15 All finances are dealt with by the resident or their relative. The home will hold small amounts, which are kept, individually in a secure location. Any transactions are signed for by 2 staff and all receipts are kept. Records required to ensure the health and safety of staff and service users were inspected. Fridge, freezer, water and cooked meat temperatures were recorded. The homes gas landlords certificate was in date however the 5-year electrical wiring test was still not available. Risk assessments on the building and staff/service users activities was completed and reviewed every 12 months, and public liability insurance was in place. A fire risk assessment and evacuation plan is in place, and all equipment is regularly serviced and tested as required including portable electrical equipment. All Staff receive fire training at least twice a year. This has been broken down to 2 sessions to ensure all staff can attend. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 17 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 OP7 Regulation 14,15 Requirement Individual care plans must set out in detail what action was required to meet all the identified needs. Monthly reviews must be recorded and include signatures from the people involved including the service user. More detail and specialist information is required for those people diagnosed with dementia. This is an outstanding requirement from the 3rd March 2005. Prescribed creams must not be used for other residents. Medication belonging to residents no longer at the home must be returned to the pharmacy. Eye drops with a use by period must be dated when opened. Carpets required replacing / repair on the top floor landing. The bathroom in the old house requires a new floor. Complete a full audit of the homes furniture, fittings, decoration and repair and produce a maintenance and DS0000024971.V285324.R01.S.doc Timescale for action 01/06/06 2. OP9 13(2) 02/03/06 3. OP19 13,16,23 01/06/06 Holly Lodge Version 5.1 Page 18 4. OP26 23 5. OP33 24 6. OP38 12,13 renewal plan with dates for completion. Continue to repair or replace the loose or uneven flooring. Ensure all fire doors and closers are maintained, operating safely and door wedges are not used. This is an outstanding requirement from the 3rd March 2005. Repair or replace the dining room furniture. Remove the door lock from the outside of room number 3 (currently empty) The laundry floor must be repaired or replaced. Mops must be stored correctly. Proposed changes to the laundry room must be included in the renewal plan. The homes policies and procedures must be updated to reflect practice and take into account health and safety guidelines. This is an outstanding requirement from the 3rd March 2005. The home must introduce a quality assurance system. This is an outstanding requirement from the 3rd March 2005. A 5-year electrical wiring certificate must be provided. This is an outstanding requirement from the 3rd March 2005. 01/06/06 01/06/05 01/04/05 Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 19 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 OP19 Good Practice Recommendations The personal call alarm system, which is loud and piercing, is replaced with a lower pitched repetitive sound in more frequent locations. Holly Lodge DS0000024971.V285324.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 DS0000024971.V285324.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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