Inspection on 06/02/06 for Holly Lodge Care Home

This inspection was carried out on 6th February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Lodge Care Home 26/08/05

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 Martin Hefferman Unannounced Inspection 6th February 2006 11:30 Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 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 Care Home DS0000001751.V280714.R01.S.doc Version 5.1 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 Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holly Lodge Care Home Address 97 Fosse Way Syston Leicester LE7 1NH 0116 2692168 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) Mrs Angela Ruth Goodger Mr Martyn Anthony Goodger Mrs Angela Ruth Goodger Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 26/08/05 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, with the exception of 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, which is available for the use of residents and is 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 DS0000001751.V280714.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the establishment’s capacity to meet regulatory requirements & minimum standards of practice and focuses on aspects of service provision that need further development. This inspection took place over the course of approximately three and a quarter hours. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they receive through review of their records, discussion with them (where appropriate), staff and observation of care practices. Two residents were at home at the time of this visit. The registered persons and a member of care staff were also present. 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 Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 6 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 Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 7 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): Not applicable EVIDENCE: None of the Standards in this section were inspected on this occasion. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 8 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 Individual plans are clear and comprehensive, providing staff members with the information they need to meet residents’ needs. EVIDENCE: Individual plans were available for the residents who were chosen for the purposes of case tracking. They were clear and comprehensive. Residents have signed their plans to indicate that they are in agreement. The home was reminded that it must keep individual plans and risk assessments under review. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 9 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): Not applicable EVIDENCE: None of the Standards in this section were fully inspected on this occasion. One of the residents who were chosen for the purposes of case tracking stated that she attends a local college three days a week and that on the other two weekdays she undertakes activities with her key worker. The registered manager stated that the second resident – who declined to speak to the inspector – had ‘retired’ from her attendance at a local day centre. One of the residents who were chosen for the purposes of case tracking stated that she enjoys the food provided by the home, particularly the Sunday roasts. A menu displayed in the dining room indicates that residents receive a varied diet. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 10 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): Not applicable EVIDENCE: None of the Standards in this section were fully inspected on this occasion. Medication administration records for the residents who were chosen for the purposes of case tracking met relevant requirements. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 11 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): Not applicable EVIDENCE: None of the Standards in this section were fully inspected on this occasion. One of the residents who were chosen for the purposes of case tracking stated that she would speak to a member of staff or the registered manager if she had any concerns. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 12 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 Residents are provided with comfortable surroundings in which to live. EVIDENCE: The parts of the home that were inspected were decorated and furnished to a satisfactory standard. One of the residents who were chosen for the purposes of case tracking stated that she is happy with the environment in which she lives. The registered persons stated that they were in the process of addressing a number of minor issues that were identified during a tour of the premises (e.g. wallpaper peeling in one of the bathrooms). Progress regarding these issues will be checked at the next inspection. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 13 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 Arrangements for recruiting and training staff appear to be generally well managed. EVIDENCE: The registered manager stated that two of the five members of care staff have obtained National Vocational Qualification level 2. She reported that two members of staff are due to start NVQ 2 and one NVQ 3 later in the year. The registered persons have both obtained a level 4 NVQ in management & care. The records relating to two members of staff were inspected. One contained two written references; the other, two references obtained over the phone. Records indicate that Criminal Records Bureau disclosures have been sent for. A recommendation has been made that the home should keep a record of the outcome of each disclosure. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 14 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 Residents appear to benefit from a well run home. EVIDENCE: The registered persons have both obtained a level 4 National Vocational Qualification in management & care and the Registered Managers’ Award. They stated that they continue to update their knowledge, primarily through research on the internet. One of the individual plans that were inspected reflected the outcome of a particular piece of research undertaken by the registered manager. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 15 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X X X X X X Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? N/a 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 YA34 Regulation 19 Requirement The registered persons must obtain two written references for any person employed to work at the home. Timescale for action 06/02/06 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 YA34 Good Practice Recommendations It is recommended that the home keep a record of the outcome of each Criminal Records Bureau disclosure. Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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. Extracts may not be used or reproduced without the express permission of CSCI Holly Lodge Care Home DS0000001751.V280714.R01.S.doc Version 5.1 Page 18 - 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!