Inspection on 26/06/06 for Holly Lodge

This inspection was carried out on 26th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 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 20/02/06

Holly Lodge 10/08/05

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 Lynnette Gajjar Key Unannounced Inspection 26th June 2006 09:35 Holly Lodge DS0000023961.V294486.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.V294486.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.V294486.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) The Avenues Trust Limited Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Holly Lodge is a small 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 have behaviours that may challenge the service requiring a specialist setting. Avenues Trust Ltd owns the property 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. 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 is well maintained. The homes current scale of fees range from £1,176.55 to £1,176.55 per week. All current service users are health-funded clients. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, the first in the year running from April 1st 2006 to March 31st 2007. The visit on the 26th June 2006 lasted from 09:30 to 14:45pm. The inspection was closed at this time due to the distress and agitation being experienced by one service user at the prolonged presence of the inspector. The home currently has 4 people who live at the home and is running with no vacancies. The home does not currently have an appointed or registered manager. There is a senior support worker undertaking acting up duties for administration but who is also covering direct care hours. The visit was spent talking directly with those living at the home, both privately and collectively, with staff, and briefly with the acting manager who popped into the home. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of those living at the home in the report. Some judgements about quality of life and choices were taken from limited conversation with those living at the home, and direct observation followed by discussion with care staff and evidencing records. A tour of the premises was undertaken, with time spent assessing various records and case tracking. Information was also gathered through a pre inspection questionnaire completed by the senior support worker and comment cards returned to the Commission. Documentation was in good order despite low permanent staffing levels. A number of CSCI “comment cards” (questionnaires) were sent out to relatives and professionals involved in the home. Those returned included GP, 2x Health Professional and 4x relatives/visitors. Comments included: “My son (Name of service user) is happier and better cared for than at any other time of his life” “I would like to thank the staff on (Name of Service user) and my own behalf.” Direct comments from service users included: “I like it here” “Nice here” “She’s nice she is” referring to a staff member “(Name of staff) he’s my key worker” Due to serious concerns regarding safe and adequate experienced/competent staffing to meet the assessed needs of service users and the lack of an Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 6 appointed designated manager to the service; the Commission has issued an immediate requirement from this visit. A written response is required from the Responsible Individual by return post regarding action to be taken to address these as a matter of urgency. This is the first level of enforcement action regarding staffing at the home. What the service does well: What has improved since the last inspection? What they could do better: Service users and the staff team would benefit from more direct leadership and management through the appointment of a permanent manager to the home with clear lines of management accountability within the organisation structure at times of vacant positions and sickness. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 7 Service user and staff would feel more secure and safe though the recruitment of permanent staff to the existing 161.25 vacant hours from 3rd July 2006, out of the home’s allocated 268.25 hours (7.25 WTE staff). Service users and the current staff team would benefit from the vacant posts being covered initially (whilst recruiting) by regular bank or agency staff, who have been trained, have the experience and familiarity of service users and their care needs. Relieving permanent staff from additional shifts, potential fatigue and the higher risk of errors of judgement and personal safety. Service users would feel less anxious about being involved in aspects of their daily lives by being encouraged to take part in the local community, follow personal interests at a pace suitable to them and not being rushed, not understood and frustrated due to the limited care staff who know them. Through the review and refurbishment of current kitchen and laundry facilities, this would ensure effective infection control management and cleaning of wooden units, broken and dangerous drawers, wooden door handles, broken and cracked tiles and skirting being replaced, which would guarantee service users a safe and accessible food preparation area and continue to promote personal aspiration and development needs. Service users would benefit by having more competent and skilled staff assessed through the NVQ in care qualification, of the current five care staff only one holds NVQ 2 or above. Service user and staff would feel more secure in the knowledge that alternative filing of accident/ incident records is given serious consideration and stored to ensure compliance with Data Protection Act and confidentiality. 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 DS0000023961.V294486.R01.S.doc Version 5.2 Page 8 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.V294486.R01.S.doc Version 5.2 Page 9 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): 1,2,3,5 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service Users and representatives have access to the information needed in making a decision if the home can best meet their needs. Current low permanent staffing levels are compromising individual assessed need, direct care, aspirations and behaviour management. EVIDENCE: Service user guides seen today were in both clearly written and pictorial formats. It was acknowledged by the staff that minor adjustments to staffing details were needed for both the service user guide and statement of purpose and copies would be forwarded to the Commission on completion. All Service users have lived together for the past six years; there is no evidence of changes to the current tenants at present. No new admission has occurred to assess this area fully. However files seen held assessments from health professionals. The Avenues Trust has a detailed admission and discharge procedure to follow if a vacancy did occur. Due to the current low permanent staffing levels by those who are familiar to service users, individual assessed need, direct care, goals and behaviour management is being compromised, although the permanent and temporary Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 10 staff are working hard to address this, however, this is causing unnecessary stress and incidences that could be avoided. Service user’s guides seen today contained a written tenancy agreement/contract, which gives the persons’ security and rights of residency to Holly Lodge but does not give details of the actual private room assessed as best meeting their care needs. This document clearly lays out the tenant’s and landlord’s rights and responsibilities. Service users had signed contacts seen. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 11 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): 6,7,8,9,10 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Person centred care plans, risk assessments and guidelines continue to develop offering detailed information to ensure consistent support by staff. However the current low levels of permanent staff are compromising individual assessed need, direct care, choices and behaviour management. EVIDENCE: Through discussion with a staff and assessing three current care plans, it is clear that service users are given full support and encouragement to maintain personal contact with health and social care professionals, to maintain good standards of health and social care. Guidelines and risk assessments enable staff to access information that is most important and to maintain individual and collective safety. Photographic and pictorial formats are used to aid communication and better understanding by service users. Daily write ups were discussed with some good entries that really gave the reader a good understanding of how the day had gone for the service user, how they felt, what they had done and needed help with. There were others Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 12 that required more detail. Permanent staff evidenced a clear and practical understanding of service users needs. Despite the low staffing at present monthly key worker reviews and six monthly PCP reviews have taken place due to the commitment of permanent staff. Interaction between service users and permanent staff continues to be good showing genuine respect, friendship and appropriate familiarity with each other. Often with appropriate two way banter and fun. However it was clear due to the lack of experience and knowledge of temporary staff, service users are presented with additional anxieties and lack of skilled support causing potential conflict, breakdown in behaviour and harm. Due to this (although commendable for their commitment to the service users), permanent staff were observed to be ‘run ragged’ over a shift to ensure some community activity; individual routines are maintain although restricted for service users. Records seen were stored securely. To comply with Data Protection Act alternative storage of the yellow accident form was discussed and to be implemented by staff with the senior support worker. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15,16,17 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are given encouragement and support to make choices about a range of local social and recreational interests. However this is currently restricted due to low permanent staff to support service users safely and a pace suitable to them. EVIDENCE: Service users are supported in accessing the local community and go for lunches out to cafes, public houses and restaurants. This however has been limited recently due to low permanent staffing levels. Due to confidence of staff one permanent member of staff was responsible this morning to ensure all service users got to undertake their planned banking trip (which required two trips due to safe staffing levels and behaviour management in the community). This was followed by a short lunch out with another service user. This morning presented as being very rushed and demanding on the one staff member it also left for long periods of time, three service users and one agency staff member at the home. All service users present at times with behaviour that can challenge the service. A service user was very anxious Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 14 about a staff member who was leaving and became more distressed throughout the morning. This caused other service users stress and intolerance of their peer. This was a compromising situation that could have been volatile through mismanagement and lack of understanding by an unfamiliar temporary staff member. Internal activities include art and craft sessions, video/DVD and one service user continues to enjoy singing along to karaoke. A service user has been away to Butlins for a short break but due to current staffing levels other holidays have been postponed, much to the disappointment of service users. All service users continue to be registered 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. Service users were seen to be offered a varied and nutritious choice of menu’s and food that they preferred. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 15 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 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health, social and personal care needs of those living here are well supported with contact with specialists and external professionals. The gentlemen are treated with genuine respect and dignity by care staff and are protected by appropriate medication procedures. EVIDENCE: Permanent staff is clearly aware as to the type and nature of the support required for individual’s personal and intimate care needs. Every effort is made to maintain privacy and dignity when people are being supported with bathing, washing and dressing as well as behaviour management interventions. Use of agency and bank staff who are not familiar with specialist care and behaviour management strategies could compromise individual stability and coping strategies at times of high anxiety such as staff changes and cancelled activities. Care plans indicate staff have a good understanding of individual physical and emotional needs. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 16 Good practice in relation to medication management and storage is in place. MAR Sheets are clearly written with clear PRN guidelines of administration. One staff member tends to take lead in the ordering and returning of medication. Service users expressed fondness and affection towards permanent staff but anxiety was evident with current low levels of permanent staff and a further staff leaving that weekend, particularly as they were their allocated key worker. Constant reassurance was required by staff to this service user. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 17 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 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Systems are in place to enable those living and those visiting the home to raise concerns or complaints with staff and people they trust. Protection from abuse is developing through staff training and understanding of the support and actions they may need to take. EVIDENCE: The home has a clear complaint procedure both in written and audio formats. Due to the nature of the service and those living here, using this system is limited. It is evident that service users would be quite heavily reliant on a relative/ advocate/staff identifying concerns and raising them on their behalf. Two of the four relative feedback questionnaires received indicated that they were not aware of the complaint procedure. The pre inspection questionnaire completed by the acting manager indicates no formal complaints have been received. Staff who have been spoken with evidenced a realistic understanding of how to protect and prevent abuse, including reporting under local procedures. One adult protection issue is currently under investigation with the local social services dept and due to current staffing issues this has been referred to funding authorities via the Adult Protection Protocols. Due to the nature of the service, a number of service users due to personal safety and behaviour management strategies, have restraint guidelines in Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 18 place. Full risk assessments are in place including agreement of all relevant stakeholders as in the best interest of the service user. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28,30 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users live in a generally comfortable and homely environment, which would be enhanced further by the refurbishment and replacement of kitchens to promote good food hygiene standards, the completion of redecoration of communal areas and personal bedrooms. Including the consideration of further communal space that can be used in private. EVIDENCE: Holly Lodge is a detached purpose built bungalow situated in a remote part of Hildenborough. There is a separate lounge and dining room, kitchen, bathroom, separate laundry room and 4 single bedrooms. There is a sleepin/office room for staff. There is no private communal space other than returning to service user’s private rooms. This can cause difficulties in meeting preferred social preferences in activities and private time. The home continues to be presented to good standard cleanliness. Some redecoration of the home has taken place but there are still areas that require urgent attention. Bathroom flooring has been replaced. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 20 The home has replaced the three-piece suite since the last inspection. Further improvements to infection control management can be made through ensuring seals around toilets are effective, reviewing current kitchen and laundry units, shelving, door handles and work surfaces are compatible to good infection control practice, especially as service users are encouraged to be actively involved in preparation of food and drinks. Replacement of kick boards identified in previous inspections remains outstanding. Bedrooms are adequately furnished and decorated to the preferences of service users and personal possessions were displayed reflecting the personalities and lifestyles of service users. One bedroom has an on going problem with damp staining patches on the ceiling and requires action to address this. Specialist equipment is currently not assessed as required. One service user is visually impaired and manages exceptionally well in orientation around the home. Staff ensures furniture is not moved to assist this. Other service users have deteriorating eyesight and hearing. But the service users had good special awareness and ability to move around the home freely. Care plans tracked evidenced support from Kent Association for the Blind. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 21 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 Quality on this outcome area is poor. This judgement has been made using available evidence including a visit to the service A small permanent staff team that receives good training and supervision supports service users in meeting individual needs. Service users would benefit by stabilizing the staff team through positive recruitment to the high ratio of vacant positions currently experienced. EVIDENCE: The home is currently running with 144 hours permanent staff of the 268.2 (7.25 WTE) allocated for this home. This includes the 37 hours acting manager’s hours as working shifts to cover direct care. Rosters from 3rd July showed a drop of permanent staff to 107 hours per week. A number of shifts seen remained un-covered with the senior support worker trying to make sure one permanent staff is doing extra shifts to offer consistency before contacting the agency to cover the rest. Saturday 8th July still required two late shifts and sleepover to be covered. The roster evidenced 107 – 129 hours per week being covered by existing staff doing extra shifts or Manager fulltime at Laurels and where this was not arranged Agency staff were the final roster cover. This is of serious concern to the Commission and exceeding safe working hours and exposing service users Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 22 to risk of tired and stressed staff this may lead to errors in care and support provided but also leaves inexperienced temporary staff to manage some challenging behaviours presented by service users who thrive in routine, security of familiarity and adverse reaction to changes. Today (26th June) there was one permanent and one agency staff covering 82pm with two permanent staff covering 2-10pm. The site visit evidenced that service user’s support needs are being compromised. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 23 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, 39,42 Quality on this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home does not have a manager or leadership in place to enable the service to develop and promote personal preferences of service user’s support and care needs, this potentially could put residents and staff at risk. EVIDENCE: A suitably competent and qualified manager has not been appointed to Holly Lodge or a clear management structure and lines of accountability established since the managers’ transfer to another home at the end of April 2006. Staff confirmed a Senior Support Worker completed the pre- inspection forms and was stated by staff to be working within the role of acting manager as well as covering direct care shifts. This senior support worker does not hold NVQ 2, 3 or 4 qualifications. The Service Manager is currently on sick leave and staff through discussion was unsure of interim management arrangement for support to the home from senior managers within the Avenues Trust Ltd. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 24 The inspector acknowledges that the acting manager and remaining permanent/bank staff have strived to maintain continuity and undertake additional work and shifts. However this cannot be continued over a long period of time in a safe and productive manner. Service users care and support is being compromised. Regulation 26 visits have been undertaken at least monthly by the service manager with action plans to address areas identified. Service users meet weekly to discuss current week plans and menus. Information from Pre inspection questionnaire indicates appropriate servicing of the home and supplies are in date and current. An up to date certificate of insurance was on display. Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 25 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 2 2 1 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000023961.V294486.R01.S.doc 3 2 2 2 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Lodge Score 2 2 3 X 1 X 2 X X 2 X Version 5.2 Page 26 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 YA10 Regulation 17 Requirement Records 17 (1) (b) In that accident /incident records are filed to comply with data protection and freedom of information Acts. Full action plan with proposed completion dates to be submitted by 31/07/2006 Health and Welfare 13(3) The registered manager shall make suitable arrangements to prevent infection and spread of infection at the care home. In that: 1) Advised is sought from infection control unit regarding infection control management of each unit and recommendations action taken. 2) Kitchen wooden doors, handles, work surfaces, kick boards and damaged shelving are replaced to ensure effective infection Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 27 Timescale for action 31/07/06 2 YA30 13(3) 31/07/06 control management and cleaning. Full action plan with proposed completion dates to be submitted by 31/07/2006 Regulation 18 (1) (a)(b): Staffing. The registered person shall having regard to the size of the care home, statement of purpose and number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home to meet the health and welfare of service users. Ensure that any employment of person on a temporary basis at the care home will not to prevent service users from receiving such continuity of care as reasonable to meet their needs. Immediate requirement issued written response required by return post Regulation 8: Appointment of a manager. The registered person shall appoint an individual to manage the care where there is not manager in respect of the care home, where a person is appointed supply forthwith to the commission the name and the date of appointment is to take effect. Immediate requirement issued written response required by return post 3 YA32 18 27/06/06 4 YA37 8 27/06/06 Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 28 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 YA1 Good Practice Recommendations It is recommended amendments required to the service user guide and statement of purpose are implemented and a copy supplied to the Commission and Service users within 28 days of revision. It is recommended that contracts are reviewed to ensure they include the room to be occupied and that this room meets their It is recommended families and advocates are made aware of the homes complaint procedure. It is recommended that work be undertaken to address damp patches in the identified service user’s bedroom. It is recommended that there should be a designated private area for visitors. It is strongly recommended at least 50 of the care staff team achived NVQ in Care Level 2 or above. It is strongly recommended radiators are risk assessed to ensure safe use and where identified guarded or radiators that are low surface temperature. 2 3 4 5 6 7 YA5 YA22 YA25 YA28 YA32 YA42 Holly Lodge DS0000023961.V294486.R01.S.doc Version 5.2 Page 29 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.V294486.R01.S.doc Version 5.2 Page 30 - 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!