Inspection on 05/09/05 for Holly Lodge

This inspection was carried out on 5th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holly Lodge 03/04/07

Holly Lodge 13/11/06

Holly Lodge 02/03/06

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 DY8 2HA Lead Inspector Mike Kirton Unannounced 5 September 2005 th 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 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 E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holly Lodge Address 9 Rectory Road, Oldswinford, Stourbridge, West Midlansd, DY8 2HA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01384 373306 01384 378160 Mr Mohammed Iftikhar Ali Mrs Paula Hubble Care Home 21 Category(ies) of Dementian (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 E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd March 2005 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 E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours and included interviews with 6 residents in private and group discussions in the 2 lounge areas. The manager, proprietor, deputy manager and 3 care staff were also interviewed and a tour of the building took place. 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 E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,&5 Improvements have been made to the homes admission procedures and careful consideration is given to ensure residents needs, can be met. Feedback from residents further demonstrates that they have sufficient information to make an informed choice before moving into Holly Lodge. EVIDENCE: Intermediate care (Standard 6) is not provided. The home has a statement of purpose and service users guide, which includes all the required information as outlined in the minimum standards. These along with a copy of this inspection report should be made available in appropriate formats, to anyone receiving or requesting accommodation at the home. The individual files for 2 residents recently admitted to the home were examined. Both contained an assessment carried out by the home and one had written confirmation that their needs could be met. Assessments carried out by other professionals involved in their care were not obtained or sent after the admission took place. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 8 Visits to the home are encouraged before a decision is made to move in on a trail basis, however it is often only the relatives who view the home. Contract were both signed and dated and a copy of the funding agreement with social services completed. The home needs to develop an admissions procedure and would be advised to use this as a checklist to ensure all future admissions are made to the minimum standards. This can also be used as a checklist to implement care plans and risk assessments and as an induction for the new resident to follow. Consideration should also be given to sending out referral forms to ensure all the necessary information is received. Feedback from residents praised the level of care provided and the way they had been made to feel welcome when they first moved in. Comments included ‘it is a perfect home’, staff are wonderful’ and ‘the food is excellent’. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7&8 The standard of care plans need to be improved to ensure that all staff are aware of what actions are required to meet individuals needs. Risk assessments must also be implemented to ensure residents health and safety is protected. EVIDENCE: The care plans for 2 residents were examined. The home is in the process of continuing to update these. Of the 2 examined one was specific in the actions needed to meet the individuals identified need regarding washing and dressing. This level of description was accurate and easy to follow and should be used as a standard for all other plans. Although the standard of information varied, generally the care plans and risk assessments were incomplete, inaccurate, or missing altogether. The home must ensure that they have a good assessment and care plan in place, reviewed at least monthly, and that risk assessments are completed to reduce the occurrence of falls, prevent malnutrition, dehydration or excessive weight gain, the development of pressure sores and ensure safe moving and handling. Dependent on the level of risk an action plan must be implemented. Other areas such as violence and aggression or mental health may also need to be covered. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 10 Residents reported that all their needs were being met and that they felt safe and supported at Holly Lodge. Where one person had experienced frequent fall at home they now reported that this had not occurred again since admission. Specialist health care needs are referred to the individuals GP and District Nurse support is provided as required. Whilst it is evident that resident’s medical needs are being met, accurate and clear records should be maintained showing all planned appointments including chiropody, opticians, dentistry, and hearing examinations. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12 Holly lodge has an excellent variety of activities planned to ensure residents lead a more stimulated life. EVIDENCE: The home has a dedicated member of staff who ensures a variety of activities are organised for both inside and outside the home. They also ensure that these are suitable for all residents’ needs and abilities. A programme of events is prominently displayed in reception along with photographs of past events. These include sing-a-longs, armchair fitness, hairdressing, communion, games, parties and trips to the garden centre, tearooms and safari park. Time is also available for staff to engage with residents on a individual basis. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16&18 Improvements have been made to current procedures to ensure the safety of residents and encourage comments or complaints to be made should the need arise. EVIDENCE: The homes complaints procedure is prominently displayed and has been updated to include contact information for the Commission. No complaints have been received since the last inspection. This now meets the minimum standards. The policies and procedures for adult abuse and whistle blowing were last reviewed in March 2005. These provide clear guidelines for staff should they be concerned about the treatment of any resident. Staff are aware of these and demonstrated commitment to taking appropriate action should the need arise. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 13 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 standard(s) These standards were not fully assessed on this occasion. EVIDENCE: Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,&30 Improvements have been made to the training and induction provided. Sufficient levels of care staff are on duty and all employees demonstrated good personal skills, qualifications, experience, and knowledge of service users needs. This ensures a safe and homely environment. EVIDENCE: Discussions took place with care staff, 2 files and the rota were examined. All potential new workers are required to complete an application form before being short-listed for an interview. Copies of the form including a health declaration were held, along with proof of identification, 2 references and a criminal records check (CRB & POVA). For other staff files the manager has begun a check list for missing documents and photographs which staff must bring in. In addition to the manager and/or deputy manager, there are 4 care staff on duty from 08:00 to 12:00 and 3 care staff till 22:00 hrs. Additionally there is a cook 09:00 to 15:00 and domestic 08:00 to 14:00 hrs. During the night there are 2 waking care staff on duty. The home also has it’s own handyman to carry out repairs and maintenance. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 15 All new employees are required to complete the home induction procedure and initially work in addition to normal staffing levels. A company is now being used to provide an external 2-week induction training course. All staff have an individual training plan and action is being taken to arrange appropriate courses to meet any identified gaps. Work is also continuing to ensure care staff have the minimum qualification NVQ 2 in care or above. The home needs to implement a staff recruitment and induction procedure, which reflects practice and meets the minimum standards. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not fully assessed on this occasion. EVIDENCE: Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 18 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 5 Regulation 14 Requirement Records must be made to ensure pre-admission visits are offered and a letter is sent to confirm whether the individuals needs, can be met. This is an outstanding requirement form the last inspection. Individual care plans must set out in detail what action was required to meet all the identified needs. Risk assessments must be completed to reduce the occurrence of falls, prevent malnutrition, dehydration or excessive weights gain, the development of pressure sores and ensure safe moving and handling. . 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. Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 19 Timescale for action 05/09/05 2. 7 14,15 01/11/05 3. 8 14,15 4. 19 13,16,23 5. 6. 22 26 23 23 This is an outstanding requirement form the last inspection. All specialist health care needs including chiropody, opticians, dentistry, and hearing must be recorded. This is an outstanding requirement form the last inspection. Carpets required replacing / repair on the top floor landing and corridor between the old and new homes needs cleaning / replacing. Radiators must be covered or replaced with low surface temperature radiators. 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 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 form the last inspection. Wheelchairs must be replaced, serviced and repaired as required. 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 01/11/05 01/01/06 01/10/05 01/01/06 Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 20 7. 28 18 8. 29 18,19 9. 33 24 10. 38 12,13 11. 38 13,14,15 guidelines. This is an outstanding requirement form the last inspection. At least 50 of care staff to be trained to level 2 NVQ in care. This is an outstanding requirement form the last inspection. All information as listed under Schedule 2 must be obtained for staff working at the home. This is an outstanding requirement form the last inspection. The home must introduce a quality assurance system. This is an outstanding requirement form the last inspection. A 5-year electrical wiring certificate must be provided. This is an outstanding requirement form the last inspection. The home needs to develop an admissions procedure and staff recruitment and induction, which reflects practice and is in line with minimum standards. 01/01/06 01/11/05 01/01/05 12/09/05 01/10/05 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. 2. Refer to Standard 19 38 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. Consideration should also be given to sending out referral forms to ensure all the necessary information is received, and using a checklist to ensure care plans and risk assessments are implemented, and as an induction for the new resident to follow. E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 21 Holly Lodge Holly Lodge E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen 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 E55 S24671 Unannounced Holly Lodge V247485 050905 Stage 4.doc Version 1.40 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. 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!