Inspection on 09/01/07 for Holly Lodge Residential Home

This inspection was carried out on 9th January 2007.

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 Residential Home 26/11/08

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

CARE HOME ADULTS 18-65 Holly Lodge Residential Home 8 - 10 Station Avenue Bridlington East Yorkshire YO16 4LZ Lead Inspector Mr M. A. Tomlinson Unannounced Inspection 9th January 2007 09:30 Holly Lodge Residential Home DS0000064538.V324438.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 Residential Home DS0000064538.V324438.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 Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Lodge Residential Home Address 8 - 10 Station Avenue Bridlington East Yorkshire YO16 4LZ 01262 678508 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 Michelle Lee Mr Simon Peter Sellars Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection N/A Brief Description of the Service: Holly Lodge consists of two adjacent detached properties. The smaller of the two properties provides accommodation for a maximum of six service users who require a more independent environment and the main building accommodates a maximum of thirteen service users. All of the service users have been assessed as having a mental health problem. Having a common garden area links the buildings. The Care Home is conveniently situated for all main community facilities including the public transport network. The properties are operated as a single unit with considerable interaction between the service users accommodated in both buildings. The registered manager’s office/training room is located in the smaller of the two properties. Both properties have three floors. The main building has a stair lift providing access to the upper floors. Ramped access is available to the main entrances. The service users’ private accommodation consists of 7 single and 6 shared bedrooms. Bedrooms are only shared at the expressed wish of the prospective occupants. Emphasis is placed on the provision of social care and emotional support for the service users although some of the service users do require a degree of physical care. The primary aim of the care home is to enable the service users to recover their self-esteem/confidence and develop their independent living skills. The current accommodation fees for the service users are from £281. The maximum fee is dictated by service users’ needs and is negotiated with the placing authority before the service user’s admission into the home. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection of Holly Lodge undertaken by the Commission for Social Care Inspection (CSCI) since the change of ownership of the home. The information contained in this report incorporates information obtained during, and prior to, the inspection visit by the CSCI. The opportunity was taken during the inspection visit to have discussions with a number of the service users, the registered manager and the staff on duty. Telephone discussions were also held with a number of social care professionals and relatives of some of the service users. Reliance was also placed in observing the service users in their domestic environment and their interaction with the staff. An inspection of the premises was carried and a number of statutory records, policies and procedures were examined. What the service does well: Holly Lodge presents more as a Supported Living environment rather than a ‘traditional’ residential care home. The service users are, for example, encouraged and enabled to do as much as possible for themselves even where their actions may necessitate them undertaking a degree of risk. Emphasis has been placed on promoting the service users’ levels of independence and their integration within the community. This has been relatively successful with the majority of the service users making maximum use of the local community facilities. The service users continue to be provided with a range of social and educational opportunities to develop their skills and knowledge. From this person centred approach the confidence and self-esteem of the majority of the service users has improved. Relevant comments relating to the service users included, “The turn round in my client is unbelievable”; “I would happily place any client of mine at Holly Lodge”; “I am very happy here – I can come and go as I please” and “(service user) benefits enormously from the care and security offered by the home while at the same time enjoying remarkable freedom and privacy”. The service users are supported by an enthusiastic, competent and well qualified staff team who have obvious empathy with the service users. The staff have common aims and provide good support for each other as well as the service users. It is apparent from discussions with the staff that they are proud of their achievements and the quality of life they have provided for the service users. The staff are also provided with a good programme of training that includes professional as well as statutory subjects such as health and safety. Comments specifically relating to the staff included, “As (service user’s) advocate I am impressed by the way that Holly Lodge’s staff have supported him”; They (staff) give excellent support particularly to my client”; “ They (staff) are extremely good and I view them very favourably”; “I’ve got nothing but praise for Holly Lodge and the staff”; They (staff) take into account the Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 6 service users’ needs and their change in need. The staff are always obliging”; As far as I’m concerned the staff of Holly Lodge have saved my client’s life”; “In my opinion Holly Lodge couldn’t be better. The carers are all people I would gladly choose as a friend” and “In my job I go to a number of care homes and Holly Lodge is one of the best I’ve seen”. The staff and service users are well supported by a competent, experienced and well qualified registered manager. Not only does the manager have good managerial skills, he also has excellent leadership qualities. This has led to a highly motivated and cohesive staff team. A number of people made comments specifically relating to the registered manager and these included, “He’s an extremely capable manager”; “He (manager) has come into his own – he is very knowledgeable about mental health”; “He (manager) has got it sorted – he is one of the best. He’s got a brilliant management style and is highly respected”; “He (manager) has supported me in my personal problems – he’s great, a really nice person to work for” and “I love working here – it’s a great atmosphere. He (manager) gives us good support and allows us to do our jobs”. What has improved since the last inspection? What they could do better: The registered manager and the registered provider are aware that the décor is looking rather ‘tired’. It is therefore proposed to have both the properties that constitute Holly Lodge redecorated on a progressive basis. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Holly Lodge Residential Home DS0000064538.V324438.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 Residential Home DS0000064538.V324438.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is good. Prospective service users undergo a comprehensive pre-admission assessment process to ensure that the home can meet their needs and they are compatible with the existing service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussions with the registered manager and the staff, it was evident that the service users had been provided with a Service Users’ Guide/Information Pack although those service users spoken to could not readily locate it or remember what it contained. A Guide was, however, available for reference should a service user or visitor to the home require it. Some of the contents of the Service Users’ Guide, such as the Complaints Procedure were displayed in the entrance hall for ease of reference. The three care records examined provided documentary evidence that the service users concerned had all been fully assessed prior to being admitted into the home. These assessments were in addition to any assessments provided by a placing authority. The registered manager demonstrated a Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 10 sound understanding for the need for a pre-admission assessment to ensure that the home could meet the prospective service user’s needs and also to ensure that the prospective service user would be compatible with the existing service users. The social worker of the most recently admitted service user confirmed that the manager had undertaken a comprehensive assessment before a decision was taken to admit his client. The social worker concerned stated, “He (the registered manager) went to incredible lengths before accepting my client. He insisted on seeing (service user) in (current accommodation), having numerous discussions with me and the client and spending time deliberating before agreeing to accept my client. At the end of this I knew that the home was suitable for my client. I would happily place any client of mine at Holly Lodge”. There was also evidence that in some cases prospective service users had been provided with a ‘phased admission’ to allow them to spend time in the care home before making a final decision to be admitted on a permanent basis. This detailed, unrushed and person centred approach to admission ensured that the home could meet the needs of the prospective service user and that they had basically made the decision themselves to live at Holly Lodge. The care records also included copies of the respective service user’s Contract or Terms and Conditions of Residence. Those examined had been signed in agreement by the service users concerned. The Terms and Conditions also identified the ‘rules’ relating to smoking and alcohol. Holly Lodge Residential Home DS0000064538.V324438.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. All of the service users are provided with a care plan that provides the staff with sufficient information in order that they may meet the service users’ assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three care records examined contained individualised care plans for the respective service users. These were in addition to, but compatible with, the care plans provided by a placing authority. The care plans identified the primary needs of the service users and the actions to be taken by the staff in order to meet those needs. It was evident that the care plans had been based on the initial as well as ongoing assessments and reviews. They were tailored for the individual and identified personal idiosyncrasies such as behavioural Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 12 problems. The care plans were clear, unambiguous and meaningful. In addition to the primary care plan the records also included information of the service user’s wishes following their death, a risk management plan, review summaries, a profile of the service user concerned and inventory of their personal belongings. Those care plans inspected had been signed in agreement by the respective service user. It was noted that some of the ongoing assessments had not been signed or dated and consequently it was not possible to verify when the assessment had been undertaken and by whom. There was recorded evidence that the care plans had been regularly reviewed. The home’s staff and social service’s staff confirmed this. The service users had been encouraged to attend the reviews of their care plans but only a few did so. Their decision not to attend had been respected by the home’s staff. It was evident that following these reviews the respective care plan had been updated. The home operated a staff ‘key worker’ system with each member of the care staff being allocated two or three service users. The primary aim of the key worker was to ensure that the needs of the service users were being met and that any change in need would be quickly identified and acted upon. The key workers had direct input into the formal reviews of the service users. Those service users spoken to were aware of their care plans but did not show any particular interest in becoming involved in the development of their care plans. The care plans were readily available to the staff and the staff confirmed that they used them as a working document. Holly Lodge Residential Home DS0000064538.V324438.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. The service users are provided with a range of opportunities to develop the personal skills and knowledge thereby ensuring that they remained reasonably stimulated and motivated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holly Lodge presented more as a ‘Supported Living’ environment rather than a ‘traditional’ residential care home insofar as the service users were encouraged to develop their life skills, make maximum use of the community facilities and take responsibility, with staff support and guidance, for making their own decisions. The majority of the service users spent considerable amounts of time out of the home only returning for specific appointments and meals. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 14 They had a range of interests and it was one of the primary roles of the staff to enable them to follow those interests. For example, several were involved with local churches and one was a Church Warden, another was in the process of joining the local branch of the British Legion and another had shown interest in computers and the staff were helping him register with the local library in order that he could use their computer facilities. In general the service users appeared reasonably motivated and they all expressed satisfaction with the support they received from the staff. The following comment made by a service user was particularly noteworthy, “The carers are all people I would gladly choose as a friend. In my opinion Holly Lodge couldn’t be better. The manager and staff are completely honest”. Several of the Social Service’s Care Managers who had clients accommodated at Holly Lodge also echoed this opinion. Life skills training for the service users was ongoing and was reflected in their care plans. It was also apparent through observation of the staff and the service users that the staff encouraged the service users to do as much as possible for themselves. For example, they were encouraged to make their own appointments, shop for their own clothes and be responsible for their own actions. Where this was not feasible the staff provided excellent support to enable the less able service users to lead active and meaningful lives. The service users also had access to a range of community facilities including Adult Education, swimming sessions, cooking instruction at a local church and community service through an Outreach Project. Several of the service users were able to use public transport without staff supervision. One stated, for example, that he occasionally went by train to see his brother. A service user stated, “I’m very happy here. I can come and go as I please”. One service user had mobility problems and used a wheelchair when out of the home. This did not, however, deter or prevent him from leading a very independent lifestyle with only minimal support from the staff. It was concluded that the staff had achieved an excellent balance between ensuring the service users’ safety and enabling them to live reasonably independent lives. A relative of a service user commented in a survey, “ My (SU) benefits enormously from the care and security offered by the home while at the same time enjoying remarkable freedom and privacy”. It was evident from the records that the majority of the service users had regular contact with friends and family. Several comments were received from service users’ relatives either through telephone conversations or by comments in the home’s survey records. These included, “ We as a family are more than satisfied with Holly Lodge”; “As (SU’s) advocate, I am impressed by the way that Holly Lodge’s staff have supported him”; “ (SU) benefits enormously from the security and care provided by the home while at the same time enjoying remarkable freedom and privacy” and “ (SU) is as settled as he has ever been. I often see him out and about”. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 15 Until very recently the home had a dedicated cook but unfortunately the week before the inspection visit the cook suddenly became ill and passed away. This was obviously a great shock to both the staff and the service users at Holly Lodge. To their credit, however, the staff had not let their grief get in the way of providing support for the service users and they had pulled together as a team to overcome this sad event. The service users were also fully aware of this event and several had attended the funeral. One service user had written a very poignant poem about the cook that emphasised the service users’ respect that they had for the staff. The menus indicated that the meals were reasonably varied and provide a balance between healthy eating and the type of food preferred by the service users. The choice of meals was often discussed during the service users’ meetings. It was observed that mealtimes were a social event with all of the service users eating together in the dining room. Where necessary a service user’s intake of food had been monitored. This was mainly on health grounds and was invariably supported by the service user’s General Practitioner. The care records confirmed that all of the service users had been regularly weighed, unless they objected, as an integral part of their nutritional screening. Several of the service users said that they would often go to local cafés for a snack thereby further promoting their independence and their contact with the local community. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is excellent. The service users’ health and personal care needs are met through good support by the staff and external health and social care professionals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from observation of the service users and the staff that the service users are provided with excellent standards of personal care by the staff in a patient, caring and respectful manner. It was also evident that staff had developed considerable empathy with the service users and were aware, for example, of the reasons for the service users’ changes in mood and behaviour. When staff needed to be firm or directive with a service user it was carried out in a respectful and non-patronising manner. The personal care required was mainly in the form of support and guidance as the majority of the service users were capable of attending to their own physical care needs. Emphasis was placed on encouraging the service users to do as much as possible for themselves and not to become totally reliant on the staff. For Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 17 some service users this had initially been quite difficult to accept as they had been used to a more institutional approach to their care and expected the staff to things on their behalf. On the day of the inspection visit the service users were dressed in clean and appropriate clothing. The staff spoken to emphasised the importance of promoting and encouraging high standards of personal hygiene for the service users to ensure that they are socially acceptable. The records confirmed, for example, that the service users have a minimum of two baths each week and in several cases this was considerable progress for individual. This was reiterated by a Social Service’s Care Coordinator who said that before admission into Holly Lodge their client was in a very poor physical state and was totally unkempt. This service user had been transformed in a physical and social sense. The Care Coordinator stated, “ The turn-round in my client is unbelievable. This comes from the quality of care, love and support (for the service users) and the fact that there is a stable staff team (low turnover). As far as I’m concerned the staff at Holly Lodge have saved my client’s life – he was in such a poor state before he went there” and another said, “One of my clients sometimes displays inappropriate behaviour. They (staff) give him fabulous support”. It was apparent from discussions with social care professionals that the staff of Holly Lodge had not hesitated in obtaining advice should they be faced with a situation that they found difficult to resolve. This had led to excellent standards of multi-agency working. It was apparent from the home’s records and the pre-inspection information provided by the registered manager, that the service users had good access to health care services. Several examples of this were provided. A service user said that they had recently had new digital hearing aids fitted, which had improved his quality of life. All of the service users had been registered with local medical practices with a variety of General Practitioners. It was apparent from the records that the service users’ state of health had been regularly monitored and any problems identified had been dealt with at an early stage. The home continued to use a Monitored Dosage System (M.D.S.) for administration of the service users’ medication. Some one-off medications, ointments, liquids etc. were administered from their original container as it was not practical to include them in the M.D.S. None of the service users were assessed as being capable of safely administering their own medication and therefore their medication was administered by trained staff. The only exception to this was service users who required the use of inhaler. The medication was appropriately stored being secured in a dedicated drugs trolley that was secured to a wall when not in use. The home had a policy and procedure for the storage, administration and disposal of medication. A copy of the procedure was in the drugs trolley for easy access for the staff. From a description of the procedure provided by a member of staff, it was considered efficient and safe. No controlled drugs were in use but arrangements were in Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 18 place should the need arise. The medication records were examined and found to be complete and up to date. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. The internal and external support provided for the service users should ensure that any incident of alleged abuse would be quickly identified and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was an appropriate complaints procedure in place. To enable the service users and visitors to the home to have unrestricted access to the procedure, it was displayed within the entrance hall. The majority of the service users at Holly Lodge had reasonable levels of literacy skills and consequently were able to read, understand and use the complaints procedure. They also had good access to representatives of their placing authority so that a service user could channel a complaint, if they so wished, via their Care Coordinator. It was evident that the registered manager encouraged service users and visitors to the home to raise any concerns directly with him. Visitors to the home and the more able service users spoken to confirmed this. Whilst there had been no complaints received by the home during the past year the manager had developed a ‘complaints follow-up’ record to identify the action take following a complaint. The registered manager viewed complaints positively and saw them as part of the Quality Control process. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 20 All of the staff had received training on Adult Protection procedures. It was evident from discussions with them that they had a sound understanding of the procedures and particularly the indications and types of abuse. Without exception the staff saw the safety and welfare of the service users as being their primary duty and said that they would have no hesitation in reporting an alleged incident of abuse. The home had a comprehensive Adult Protection policy and procedure that incorporated a Code of Conduct for the staff and a restraint policy. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30 Quality in this outcome area is good. The service users are provided with suitable accommodation that meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holly Lodge consisted of two adjacent detached properties. One property provided accommodation for six of the more independent service users and had dedicated facilities for them. The registered manager’s office/staff training room was also located in this building. The two properties were linked through the use of an inter-communication system so that staff could summon assistance without leaving the premises. There was considerable interaction between the service users accommodated in the two buildings with all of the Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 22 service users normally having their meals in the main building. Long-term the registered person hopes to have the two buildings physically joined together. Externally there was no evidence that Holly Lodge was a care home, which consequently minimised the possibility of stigmatisation of the service users. On the day of the inspection visit the care home was warm and clean. Although the décor in the communal areas in particular was of an acceptable standard, it looked ‘tired’ and would benefit from being upgraded. Both the registered manager and the registered person were aware of this and action had been planned to address the standard of decoration. Two Care Coordinators also commented upon the standard of the décor. It was noted that the stair carpet was starting to show signs of wear and will require replacing at some stage. A maintenance programme had been developed and a maintenance person is to be employed as from the end of this February. The main property had two lounges with one dedicated for the use of service users who smoked cigarettes. The lounges and dining room were furnished to an acceptable standard. The service users’ bedrooms were decorated and furnished to a good standard. The majority of the service users had single accommodation. Shared accommodation had only been provided for those service users who had made a considered decision to share. For example, two sisters, who confirmed that they did not want to be separated, occupied one large bedroom. The bedrooms had been personalised by the occupants and in many cases the rooms were more akin to bed-sitting rooms. All of the rooms inspected had lockable facilities for the use of the occupant. It was evident from discussions with several of the service users that they were satisfied with their accommodation and some even displayed a degree of pride with regard to their rooms. There were adequate numbers of baths and toilets available that provided appropriate levels of privacy for the service users. Some of the bedrooms had commodes available for the occupant. In the majority of cases these commodes were of an old design and consequently were rather conspicuous. The manager provided confirmation that the commodes were progressively being replaced by some of a more modern and less obvious design. The radiators did not have safety guards fitted. Whilst the service users were not deemed as being particularly at risk, the lack of radiator guards had not been made the subject of a formal risk assessment. The home had good laundry facilities. The service users confirmed that their laundry was done on a daily basis. Appropriate facilities for the disposal of Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 23 soiled materials were available and staff had access to disposable protective clothing. The two properties had a linked large garden. This was maintained to an excellent standard and there was evidence that the service users used it particularly during the summer months. There was ramped access at the front of both properties to assist those service users who had mobility problems. The properties did not have a passenger lift and consequently were only considered suitable for service users who were reasonably ambulant unless they were able to have accommodation on the ground floor. As far as could be ascertained from the home’s records the properties satisfied the specific requirements of the Fire and Environmental Health Departments. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is excellent. The service users are supported by competent, experienced and enthusiastic staff who have the saw the needs and welfare of the service users as being their priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holly Lodge had a very stable staff team with only one new member of staff having been recruited in the last twelve months. Many of the staff and service users had been at the home for a considerable number of years. The staff presented as being enthusiastic about their job and regardless of their role they all held a common aim to improve the lives of the service users. They had established a close but professional relationship with the service users and displayed an excellent understanding of the service users needs and personal idiosyncrasies. Comments from the staff included, “ I love working here – it’s a great atmosphere”; “I’ve worked here a long time and I wouldn’t want anywhere else. I look forward to coming to work”; “I love my job” and “I was a bit afraid of the residents at first but now I see them more as friends – Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 25 they’re great”. The service users thought highly of the staff and one said, “The carers are all people I would gladly choose as friends”. The service users’ relatives and representatives of social services further reiterated these commendations of the staff. Their comments included, “They (staff) give excellent support particularly to my client”; “They (staff) are extremely good. They have a stable staff team and they work together. They have established a good relationship with external agencies. I have nothing but praise for Holly Lodge and the staff”; “They seem to care well – they cope well with the highs and lows of mental health. They are flexible towards the care plans and take into account the service users’ needs and changes in need. I’m always well received and staff are always obliging. I don’t have any concerns”; “ As an advocate I am impressed by the way that Holly Lodge’s staff have supported (service user)” and “ The care is fantastic – this comes from the quality of care, love and support”. It was concluded that the staff were operating as a cohesive team with common aims and that they had impressive levels of empathy with the service users. From an examination of the staff records and discussions with individual members of staff it was apparent that the staff had been provided with a range of training opportunities. These included training on professional as well as statutory subjects. The majority of the care staff had obtained a National Vocational Qualification at level 2 or above. A programme of training was in place. It was evident that there were sufficient staff available to meet the needs of the service users and that the level of staffing was flexible to take into account any change in need. Regular staff meetings had been held and minutes kept of these. The staff had also received regular supervision sessions. The staff had received contracts of employment and meaningful job descriptions. The home had robust staff recruitment and vetting procedure. This included obtaining personal references and prospective staff undergoing a Criminal Record Bureaux check. This recruitment process was verified by the staff records and through discussions with the staff on duty. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 and 42. Quality in this outcome area is excellent. The service users and staff are supported by a competent, experienced and highly qualified manager thereby ensuring that the staff were able to provide good standards of care for the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager had been employed at Holly Lodge for over twentyfour years. During that time he had obtained three relevant National Vocational Qualifications at level 4 as well as taking the opportunity to develop his managerial skills through other forms of training. Prior to the change in Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 27 ownership of the care home, the registered manager had the immediate support of the registered person as she was invariably on the premises. Since then, however, the registered manager has had greater managerial autonomy and had undertaken increased levels of responsibility for running the home and making decisions. From all accounts he has taken to this with little or no problems. The comments received from the service users, their relatives and social services representatives included, “He is an extremely capable manager. He takes care that new clients will fit in”; “He (manager) has come into his own – he is very knowledgeable about mental health”; “He (manager) has got it sorted – he is one of the best. He is always consistent in his approach. He’s polite but assertive. He’s got a brilliant managerial style – he’s highly respected” and “He will discuss any problems with me”. This obvious high level of respect was also echoed by the staff who felt that they received excellent support from the registered manager both on a personal and a professional basis. The manager had delegated appropriate tasks to staff thereby increasing the level of their responsibility. He also had the support of a competent, experienced and qualified deputy manager. The registered manager was very aware of equality and diversity issues and the need to ensure that all of the service users had similar opportunities to develop their skills and personalities. This had been incorporated into the service users’ care plans. He had also ensured that equality and diversity had been addressed during the admission process so that any prospective service user would not be at a disadvantage from joining an established group. There was Quality Assurance and Control process in place. This included actively obtaining feedback from users of the service and from visitors to the home. As an integral part of the process, the registered manager had regularly audited individual elements of the service such as social activities, medication procedures and training. These were all included in an Annual Service Report which was then turned into an Annual Development Plan that identified the actions to be taken to address any weaknesses in the service. A number of statutory and non-statutory records were examined. These had been well maintained and where necessary, cross-referenced to ensure continuity of the record keeping. The registered manager provided evidence that the home’s policies and procedures had been, and were in the process of being, reviewed and updated. The staff had all undergone training on health and safety as well as associated subjects. The safety records such as the Accident and Fire Records were complete and up to date. With the exception of the radiators and the need for safety guards, risk assessments had been undertaken and recorded. It was concluded that the manager had taken all reasonable action to ensure that the premises were safe for the use of the service users and the staff. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 28 Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 29 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 3 2 4 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 4 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 4 4 X 2 3 X Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 30 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 YA24 Regulation 13(4) Requirement Those radiators that do not have safety guards fitted must be the subject of recorded risk assessment. Timescale for action 01/03/07 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 YA41 Good Practice Recommendations All records maintained on the service users, in particular the assessments, should be signed and dated by the person compiling that record. Holly Lodge Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Residential Home DS0000064538.V324438.R01.S.doc Version 5.2 Page 32 - 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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