Inspection on 20/02/06 for Holly Lodge

This inspection was carried out on 20th February 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 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 10/08/05

Holly Lodge 23/02/05

Holly Lodge 16/08/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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 Announced Inspection 20th February 2006 09:30 Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 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.V273612.R01.S.doc Version 5.0 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.V273612.R01.S.doc Version 5.0 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) The Avenues Trust Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 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 accommodation 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 that 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 DS0000023961.V273612.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory inspector Paul Stibbons conducted this announced inspection on the 20th February 2006 from 09.30 until 14.00 hours. The pre-inspection questionnaire along with 4 comment cards were returned to the CSCI prior to the inspection date. A tour of the premises was undertaken and a number of records and documents were examined. The inspector spoke with 2 service users and staff on duty. What the service does well: What has improved since the last inspection? What they could do better: There remains an outstanding requirement to repair skirting in the kitchen and a recommendation to repair or replace kitchen units. Only 33 of the staff team (including bank staff) hold an NVQ in care and it is recommended that this percentage be increased. Please contact the provider for advice of actions taken in response to this Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 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 the following standard(s): 2, 4, 5 Comprehensive assessments and a trial visit ensure the home is able to meet individual needs. EVIDENCE: Service user files viewed evidenced that comprehensive assessments had taken place that covered physical, social and emotional needs. Care plans contained individual written contracts outlining the terms and conditions of the placement. Individual support plans based on assessment findings were in place for each service user. There have been no new service users for some time but the manager stated there is a policy in place to enable visits and trial periods before either party commits to a permanent placement. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 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 the following standard(s): 7, 9, 10 Service users are encouraged to make choices and supported to take risks as part of an independent lifestyle. Their right to confidentiality is upheld. EVIDENCE: Care plans viewed evidenced risk assessments and support requirements for activities engaged in by service users. Service users spoken with stated that the décor in their rooms was to their choice. They are involved in the choice of menus and supported in assisting with preparation of food. Confidential records were seen to be securely stored. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14, 16 Service users participate in a range of activities within the home and in the local community. EVIDENCE: Service users are supported in accessing the local community and go for lunches out to cafes, public houses and restaurants. Visits to the resource centre, bowling venue, Assembly hall shows, pantomime and London have been taken. Internal activities include art and craft sessions, video/DVD and one service user was observed singing along to karaoke. All service users are on the electoral role but only one service user wishes to vote. The rights of service users were upheld in gaining permission to enter rooms and using their preferred mode of address. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 18, 19, 20,21 Service user healthcare needs are assessed and recognised and they are supported in accessing healthcare facilities locally with prompt referral to appropriate specialists where required. EVIDENCE: Each service user has a designated keyworker and individual records set out likes and dislikes and preferred routines. Care plans evidence regular monitoring and recording of body weight and other routine health checks and referral to healthcare professionals when necessary. Medication was seen to be stored in line with guidelines from The Royal Pharmaceutical Society of Great Britain. Mars sheets were completed accurately. PRN protocols were in place and gave clear directions, they were signed and authorised by the prescribing GP. The wishes of service users in respect of illness and death were recorded in individual care plans. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 22, 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: The home has complaints procedures in place in written, pictorial and audio format to cater for service user communication needs. Resident and keyworker meetings are regularly held where concerns can be raised by service users. Training files viewed evidenced that adult protection training is up to date for all staff. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 24,28, 29, 30 Service users benefit from living in a homely and comfortable environment with adequate personal and communal areas. EVIDENCE: The home has adequate furniture of a good standard to create a homely and comfortable environment for service users. Individual bedrooms reflect the interests and lifestyles of service users, two service users spoken with confirmed they were happy with their rooms. The lounge and dining area are comfortably furnished and meet the needs of service users. They also have access to a well-maintained garden area. One service user with a visual impairment is, with the support of staff, constructing a sensory board of different textures. There are adequate laundry facilities that are sited away from food preparation areas. A requirement from the last inspection to replace skirting in the kitchen has still not been met, the skirting is missing and there is no seal with the flooring, this does not allow for satisfactory hygiene conditions and remains a requirement. In addition there are two kickboards missing from kitchen units that need replacing. On the day of the inspection the home was clean and tidy with no offensive odours. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 14 Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Service users are supported by appropriately trained, and supervised staff, and they are protected by the homes recruitment policy and procedure. EVIDENCE: Staff members spoken to demonstrated a good understanding of service user needs and training files viewed evidenced appropriate training to meet the individual and joint needs of service users. 9 members of staff (inclusive of part-time and bank staff) are employed, only 2 have completed NVQ3 and 1 is currently working towards. It is recommended that more staff should enrol on this training. Supervision takes place on a regular basis, the senior supervises support workers and the manager supervises the seniors. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42, 43 Service users benefit from a well run home where their rights and best interests are safeguarded and there is a competent and accountable management structure. EVIDENCE: The home is run by a competent manager who is registered with the CSCI. Staff state they have the utmost respect for the manager and felt there was openness and transparency on all issues concerning the home. There are effective quality assurance systems in place through self-assessment, resident meetings, annual surveys and frequent health and safety checks. Policies and procedures are in place to promote the health safety and welfare of staff and service users. The home’s manager is involved in development planning and budget setting for the home. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 17 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 X 3 X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Lodge Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X 3 3 DS0000023961.V273612.R01.S.doc Version 5.0 Page 18 YES 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 25/05/06 1. YA24 16(2)(j) Make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. In this context attention to the kitchen flooring and skirting.(Previous timescale 25/10/05) 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 A planned maintenance programme to repair or replace kitchen units. Holly Lodge DS0000023961.V273612.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone 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 DS0000023961.V273612.R01.S.doc Version 5.0 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!