Inspection on 04/11/05 for Holly Lodge

This inspection was carried out on 4th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Lodge 16/01/09

Holly Lodge 05/01/07

Holly Lodge 05/05/05

Holly Lodge 24/02/05

Holly Lodge 07/09/04

Holly Lodge 16/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Holly Lodge Old Hospital Road Pewsey Wiltshire SN9 5HY Lead Inspector Karen Mandle Unannounced Inspection 4th November 2005 10.00a Holly Lodge DS0000041025.V255077.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 DS0000041025.V255077.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 DS0000041025.V255077.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holly Lodge Address Old Hospital Road Pewsey Wiltshire SN9 5HY 01672 569950 01672 569952 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) White Horse Care Trust Vacant Care Home 18 Category(ies) of Learning disability (18), Learning disability over registration, with number 65 years of age (4) of places Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The staffing levels set out in the Notice of Decision dated 12 August 2003 must be met at all times No more than 18 service users with a learning disability at any one time No more than 4 service users with a learning disability, aged over 65 years of age at any one time 05/05/05 Date of last inspection Brief Description of the Service: Holly Lodge is registered to provide nursing care for 18 younger people with multiple disabilities. As a condition of registration four Service Users may be over the age of 65 years old. The home was purpose built in 2003 for the Service Users group currently living in the home. The home provides a good standard of accommodation suiting the needs of the Service Users. All 18 bedrooms are single with an en-suite facility. The home is divided into three units with six Service Users living in each unit. Holly Lodge is situated in the town of Pewsey in Wiltshire. The home is managed by White Horse Care Trust. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10.00am and was completed at 3pm. The person in charge of the home was Gill Cole RNLD who was able to assist the inspector and was open to the inspection process. The inspector toured the building visiting with service users, spoke with staff and reviewed records. What the service does well: What has improved since the last inspection? What they could do better: The care records although very detailed do lack simple instructions about how to ensure a care need is met. Pressure area and nutritional risk assessments should be used and regularly reviewed. The medication policy must be changed to address Holly Lodge as a nursing home. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 6 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 DS0000041025.V255077.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 DS0000041025.V255077.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 The pre admission assessment document will be reviewed at the next inspection, to ensure the assessment process fully meets the needs of the service users. EVIDENCE: No new admissions have taken place at Holly Lodge since the previous inspection. However it was required at that time, that the person in charge will conduct a documented pre admission assessment prior to admission to Holly Lodge. The Manager was not available at the inspection therefore this standard was not assessed but will be at the next inspection. Holly Lodge DS0000041025.V255077.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): 6 and 7 Service users are provided with a comprehensive personal care record but the records do lack simple instruction on how to meet some care needs. Service users are fully supported by the home to make personal choices where possible due to complex care needs. EVIDENCE: Each service user is provided with a comprehensive personal care record, these are detailed and include social and nursing needs but do lack simple instruction of how a care need is met. This was fully discussed with three members of staff who all had very good knowledge of how the care needs of service users were met but this knowledge was not documented ensuring that the staff provided care in the same manner to service users. It is also recommended due to the high care needs of the service users group that a nutritional and pressure area care risk assessment is completed for all service users. Family and other health care professionals are involved with the care planning process. Service users are supported to make decisions about their lives, however, due to the complex needs of the service user group, decision-making is very Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 10 limited. Service users who were able were observed spending their day as they wished with freedom of movement around the home. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 11 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 and 17 The activities provided are appropriate to the service user group. Service users are provided with a balanced and varied diet. However it would be more appropriate that a designated cook is responsible for providing the main meal of the day rather than care staff. EVIDENCE: The home continues to provide a range of activities based on the social needs of the individual service user. A large communal activities room is located centrally in the home providing an opportunity for service users from the three units to engage with each other socially. Transport is provided by the home which is used to support service users with activities outside of the home. During the summer a group of service users enjoyed a summer holiday supported by a team of carers from the home. Service users dietary needs are monitored with weights being taken regularly. Meal times are encouraged to be a social event with service users and staff eating together. The main meal of the day is served early evening, which is catered by the care staff. Domestic evening assistance is now provided. All Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 12 service users should have a nutritional risk assessment in place to ensure that all nutritional needs are being met. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 13 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 and 20 The health care needs of the service users are closely monitored and appropriate action taken when health care needs are met. The nursing and personal care provided is of a good standard. The medication procedure is safe, however the policy in place is not. EVIDENCE: Holly Lodge is registered to provide nursing care. Rotas provided evidence that a trained nurse is on duty at all times to support the nursing needs of the service users. All service users are registered with a local GP and care plans indicated that all needs are closely monitored and appropriate action taken when health care needs change. Personal care needs are fully supported in privacy by the care team. The individual appearance of service users gave evidence of how well service users are supported by the care staff with all areas of personal care. The medication procedure was reviewed. The homes’ medication policy does not relate to Holly Lodge being a home registered to provide nursing. The home continues with a weekly drug order for all service users and written medication sheets which are both time consuming tasks, undertaken by a trained nurse on duty. However, the medication procedure is safe. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 A complaints policy and procedure is in place and available to service users. An abuse awareness policy is in place however staff were not fully informed about local vulnerable adults procedures. EVIDENCE: A complaints policy and procedure is in place, a copy of which is situated in the main entrance of the home. Many service users have limited communication skills making it difficult to voice a complaint. However service users who were able to communicate stated they would speak with the manager if they had a problem. No formal complaints have been received by the CSCI regarding this service. An “Abuse” policy and procedure is in place as is a “Whistle Blowing” policy. With speaking to staff it was evidence further training is needed regarding the local vulnerable adults procedure and how to use the procedure. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25, 29 and 30 Holly Lodge provides a good standard of accommodation for service users to live in. The bedrooms are comfortable and very personalised. The home is well equipped supporting the physical needs of the service user group. The home is clean and infection control issues addressed. EVIDENCE: Holly Lodge is a recently purpose built home providing a good standard of accommodation to service users. The home is built in three units, which are all linked by a large communal area. The home has recently made major improvements to the rear garden, which now has accessibility for wheelchair users. Each service user has a single bedroom, which is individually decorated in line with the service users’ choice and well furnished. The bedrooms are very personalised and homely. All bedrooms are provided with a good size en-suite facility. The home is well equipped with specialised equipment to promote and support as much independence for service users as possible. Lifting hoists are in place Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 16 as are assisted baths in each unit. Individual wheelchairs are provided for those service users needing wheelchairs. All areas of the home were clean to a good standard with cross infection issues being correctly addressed. Clinical waste was being dealt with appropriately. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 17 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): 33 and 35. The staff team are effective and fully support all needs of the service users. The home is active with supporting staff with training appropriate to the needs of the service users. EVIDENCE: Holly Lodge has recently reviewed and re structured how the care teams on each unit operate on a daily basis to reduce workload without compromising any care issues to service users. Each unit appears to have been effective in doing this with a positive outcome for not only the staff but also the service users. Each unit is now responsible for the care teams rotas and the head of each unit, which is a trained nurse, has a more managerial role with the day to day running of the unit. Each unit appeared calmer and staff were observed spending quality time with service users. The staff receive all mandatory training. Eight trained nurses are employed to support the nursing needs of the service users and five care staff have obtained an NVQ at level 2 or 3, with a further seven carers currently working towards an NVQ award. Eight staff members have completed LDAF training and two are currently working toward obtaining the LDAF. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 Service users do not participate in a quality audit system of the home. Health and safety issues are appropriately dealt with providing a safe environment for service users to live in. EVIDENCE: It was recommended at the last inspection that a service user quality assurance tool should be implemented to gain the opinions of the service provided by the home to service users, this has not yet been done. Fire records indicated that the weekly testing of the fire alarm system was taking place and that staff had received fire training. Emergency lighting was tested monthly. The home apart from the administration offices is located on the ground floor with fire exits well signed, which were accessible at the time of the inspection. Appropriate health and safety checks are made through out the home ensuring a safe environment for service users to live in. Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 19 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 X X X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X 4 X X X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Lodge Score X 3 2 x Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 x DS0000041025.V255077.R01.S.doc Version 5.0 Page 20 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 YA2 Regulation 14 (1,A) Requirement The Registered Person will ensure that all Service Users are fully assessed prior to admission to the home. The assessment will be fully documented and retained within care records. Inspectors comment. This will be assessed at the next inspection with the manager. The organisation will ensure the assessment document is appropriate to the nursing needs of the prospective service user. Inspectors’ comment. This will be assessed at the next inspection with the manager. 3 YA20 18(3) The organisation will review the current medication policy to ensure the policy is in line with the homes nursing registration. Inspectors’ Comment. This requirement is outstanding from the previous inspection and will be addressed by the organisation. The Registered person will ensure each service user is DS0000041025.V255077.R01.S.doc Timescale for action 31/03/06 2. YA2 14 (1,a) 31/03/06 04/11/05 4. YA6 15 21/12/05 Holly Lodge Version 5.0 Page 21 6 YA6 15 provided with a pressure area risk assessment which is frequently reviewed. The Registered person will ensure each service user is provided with a nutritional risk assessment which is frequently reviewed. 21/12/05 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 YA2 Good Practice Recommendations A copy of the pre admission assessment will be sent to the organisation prior to a letter being sent to the relevant parties confirming the home is able to meet the needs of the prospective Service User. The registered person should try and order the medications monthly which are provided with monthly medication administration sheets. The Registered Person should consider introducing a Service Users survey. 2. 3. YA20 YA39 Holly Lodge DS0000041025.V255077.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000041025.V255077.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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