Inspection on 26/08/05 for Holly Lodge Care Home

This inspection was carried out on 26th August 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 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 Care Home 06/02/06

Holly Lodge Care Home 06/01/05

Holly Lodge Care Home 09/09/04

Holly Lodge Care Home 14/10/03

Holly Lodge Care Home 07/05/03

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

CARE HOME ADULTS 18-65 Holly Lodge Care Home 97 Fosse Way Syston Leicester LE7 1NH Lead Inspector Bhavna Keane-Rao Unannounced 26 August 2005 10:00am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holly Lodge Care Home Address 97 Fosse Way Syston Leicester LE7 1NH 0116 2692168 0116 2692168 None Mrs Angela Ruth Goodger and Mr Martin Goodger Mrs Angela Ruth Goodger and Mr Martin Goodger Care Home 10 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) Category(ies) of LD Learning disability(10( registration, with number of places Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 06/01/05 Brief Description of the Service: Holly Lodge is a large detached Victorian house, situated on the outskirts of the village of Syston where care is provided for 10 adults who have a Learning Disability. All of the bedrooms excepting for one, are single occupancy, and have been individually decorated according to the wishes and tastes of the residents. On the ground floor there is a large comfortable lounge and pleasant dining room. In addition to this there is a small lounge available for the use of service users and also utilised by sleeping in staff. There is a large, well-maintained garden to the side of the house with trees flower borders, vegetable patch and a paved area. Picnic tables provide an eating out area during the summer. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 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 during Thursday morning and early afternoon. It took three and half-hours to complete. This home provides care for people with varying levels of learning disabilities, upon discussion and observation it is concluded that the service provided is appropriate. Discussion was held with three of residents who were at the home. Residents were observed in their daily routine. Two resident were spoken with in detail. One resident was not spoken with in detail to their care needs The primary method for this inspection used was ‘case tracking’ which involved Three residents and tracking the care they received through looking at their records, discussion with them, and their relatives via comment cards, care staff and observation of care practices. A tour of the premises was undertaken and opportunity was taken to view residents daily records, menus of meals, fire records and staff rota. The registered owner/manger was on duty during most of the inspection. The owner/manager spent time discussing many issues that arise in the running of a residential home and facilitated this inspection. Holly Lodge is a family run business, with philosophy of care that the residents are at the core of all care provided. Before the inspection the pre-inspection questionnaire was viewed along with the last inspection. From this a plan of inspection was drawn. What the service does well: The registered owner/managers and the staff at the home are very willing to learn and improve the service provided for the residents. One resident stated, “ We go to the day centre, for walks and generally do what we want to. ” Another resident stated that “this is my home and I have lots of friends here.” Residents who were spoken with stated that they feel they are consulted about the care that this provided at this home. The interactions observed between staff and residents were very positive. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 6 Comment Cards, sent out to the home for distribution to all residents and their relatives/visitors, indicated a high level of satisfaction for the provision of care provided by the owner/managers at this home. The home has fully met all the standards inspected at this inspection, thus there have not been any requirements made. 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 Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 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 standard(s) 2 The admission process is well managed and residents entering the home are given all the information regarding the service. EVIDENCE: The admission procedures are in place and assessments of individuals are carried out by health and/or social care professionals, as part of the referral process. There have not been any new referrals to the home since the last inspection. Three resident files viewed, detailed the specific care needs of residents, identifying the needs that would be met by heath and/or social care professionals. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 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 standard(s) 6,7 and 9 The provision of social care for individual residents who live at this home is met. Care plans reflect the current care needs of residents. EVIDENCE: Three residents were spoken with about the care they received at this home. Three individual care plans of residents were viewed. One resident spoken with stated that she was very involved in what happened to her in this home. She was able to choose the food she ate, what clothes she wore and what actives she participated in. Two residents spoken with were able to demonstrate that they were consulted about their lives within the home. They were also familiar with risk assessments and the reasons for these. Review records for the existing residents were found to contain minutes of meetings and action plans. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 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 standard(s) 12,13,15,16 and 17 Residents have a stimulating and varied lifestyle at the home that is individually tailored and flexible. EVIDENCE: Residents spoken with stated that they go out and do something different everyday and that this was what they enjoy. However this not always the case as occasionally some residents will decide not to go out or are not well and so this is also accommodated. Residents have an active social life, which is encouraged and supported by the staff and occasionally their own relatives. Where residents do not wish to participate in activities then this is recorded in their individual records. Residents are supported to access the local community and social events. On the day of the inspection number of residents had gone out for their planned day care or getting ready to go out as per their in-house day care provision. Residents are encouraged to help around the home. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 11 One particular resident was very happy with the start of her Person Centred Planning. This person showed the inspector her care records and the how this fitted in care needs, hobbies and interests. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 12 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 standard(s) 18,19, and 20 Residents and staff working together to meet the physical, emotional and health care needs of residents. EVIDENCE: The records of three residents were viewed, records detailed visits made by and to health care professionals, which includes Community Nurses, Social Workers, Dentists and Opticians. Residents who were spoken with stated that they were able to decide how much input staff had in the provision of their care. Some residents are able to manage their own medication. Some residents are not able to self medicate and so there are risk assessments in place. The medication administration, recording and safe handling of medication is satisfactory. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 13 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 standard(s) 22 and 23 Residents are safe and protected from abuse. EVIDENCE: The home’s complaints procedure is displayed. Residents spoken with were aware of whom to contact and speak with should they have any concerns. The Commission for Social Care Inspection has not received any complaints since the last Inspection. Two residents spoken with stated that they felt very safe at this home. There is a procedure in place to ensure that residents are protected from any form of abuse. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 14 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 standard(s) 24 and 30 The residents are provided with a comfortable, clean and safe standard of accommodation, which individually and collectively meets the resident’s needs. EVIDENCE: The home is well maintained and suited to residents needs. There is ample natural light throughout the home. It is decorated and furnished to a good standard that creates a comfortable homely atmosphere. There are two lounges, one lounge area lead to the dining area into a kitchen which leading to the back garden. Several residents bedrooms viewed were homely with ample space. Residents are able to bring items of furniture and personal possessions with them. Two bedrooms viewed were totally individualised reflecting the interests and hobbies of the residents. Residents spoken with stated that they liked their bedrooms. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Training and supervision is in place to ensure staff are able to carry out their work safely and competently. EVIDENCE: Since the last inspection there has been one new recruitment. This is a small family run business and so some staff members are family members. At present there are ten residents for whom care is provided. There are always at least two members of staff on duty to provide care when all the residents are in the home. All the residents have a very active life and so are always out and about. Almost all the residents attend day centres during the weekdays. For people who do not attend external day care provision there is structured activities in place. Staff are supported and access specialist training to focus on meeting the needs of the residents. All mandatory staff training has been provided. The responsibilities of the staff in the home, in addition to care, include cleaning, preparation and cooking of meals, the laundry and any other tasks as identified by the registered owner/manager. However the emphasis is very much on encouraging residents to carry out independent living skills. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Residents and staff benefit from clear leadership. EVIDENCE: There are regular staff meetings, which identified the expectations of the registered owner/managers of their staff. Mr and Mrs Goodger have both now successfully completed their National Vocational Qualification level 4 and Care Managers Awards. They are congratulated for this achievement. A member of staff and the residents who were spoken with felt that they could go to either the registered owner/manager at any time with any concern. The residents who were spoken with also felt that they were involved in all provision of care and in general running of this home. Minutes of Residents meetings and care records verified this to be the case. All the staff have had formal supervisions. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 17 There is a maintenance programme for the home and the equipment. Environmental Health Officer visited the home in May 2005. A random sample of records checked was up to date including fire drills. The last Fire Security check was carried out on 6ht July 2005. Residents spoken with were able to demonstrate how to leave the building in case of a fire. One resident was aware of the recent staff training on use of fire equipment. Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 18 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 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holly Lodge Care Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 19 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 Regulation None Requirement Timescale for action 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 None Good Practice Recommendations Holly Lodge Care Home C51 C01 S1751 Holly Lodge V245751 260805 STAGE 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire LE19 1SX 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. 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