Inspection on 11/12/06 for Holly Tree Lodge

This inspection was carried out on 11th December 2006.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Tree Lodge 06/11/08

Holly Tree Lodge 20/01/06

Holly Tree Lodge 05/09/05

Holly Tree Lodge 24/02/05

Holly Tree Lodge 15/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Holly Tree Lodge 122 Spring Road Kempston Bedfordshire MK42 8NB Lead Inspector Katrina Derbyshire Unannounced Inspection 11th December 2006 14:30 Holly Tree Lodge DS0000042607.V321234.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 Tree Lodge DS0000042607.V321234.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 Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Lodge Address 122 Spring Road Kempston Bedfordshire MK42 8NB 01234 266391 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) Dr Saravanamuttu Sivapalan Mrs Sarojini Sivapalan Ms Alice Lorraine Adibi Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 7 service users may also be over the age of 65 years Service users at 01.08.03 with a physical disability may continue to be accommodated whilst their needs can be met, No further service users with mobility problems may be admitted without suitable adaptations to the building. The manager must complete an NVQ 4 in care by 31 December 2005. 3. Date of last inspection 20th January 2006 Brief Description of the Service: Holly Tree Lodge is a care home registered for up to 14 adults who have a learning disability, some of whom also have physical disabilities. To improve the rooms available for residents, the home has reduced the use of shared rooms and now accommodates up to 11 people. The registration provides for younger adults and also for seven residents of retirement age. The home also provides day care for the majority of residents. The home is situated in a pleasant residential area of Kempston, close to local amenities and a short car journey away from Bedford town centre. The accommodation comprises a main building for nine people. Three bungalows designed to promote a more independent lifestyle are located in the grounds. The bedrooms in the main house are situated on each of the two floors and access to the first floor is via a staircase. A stair lift has been fitted. Each floor has a bathing facility that has recently been refurbished. The shower on the ground floor has also been adapted for use by people with physical disabilities. The fees for this home vary from £408.19 per week, to £862.86 per week, depending on the funding source and individual needs of the residents. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this visit was to undertake a key inspection. This unannounced visit took place on 11th December 2006. The manager was present throughout the inspection. During the inspection all areas of the home were visited and the inspector spent time with many of the residents’ in the sitting area of the home and dinning room. The care of two residents’ was examined by looking at their records and interviewing the residents’ and staff who look after them. The views of residents have been used alongside information from the home through a pre inspection questionnaire to assess the outcomes within each standard. Observations of care practice and communication between the residents’ and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. What the service does well: The home continues to be very good at helping the residents to gain access to healthcare. The staff are very supportive and organised in supporting residents attend hospital appointments; see their General Practitioner or dietician if needed. When a resident feels unwell the staff act very quickly and help them get the medical treatment that they need so that they are helped to feel better as quickly as possible. The home is also very organised and has very good systems in place. This means that the residents benefit from a home that is well run, by a manager who is very clear to staff on how residents should be treated. In turn staff have a very good knowledge of the residents that live at the home so residents feel safe in the knowledge that the people who care for them are well trained and dedicated. The staff at the home are good at how they order and manage medication on behalf of the residents. They are organised in the way they order so there is always a stock of medication for each resident that has been prescribed. The medication is also stored correctly making it safer for the residents and the records that the home keeps are of a good standard, to show when a medicine has been given. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of residents are now to a satisfactory level and frequency to ensure a review of current need is in place for residents. EVIDENCE: Through examination of documentation within the home and discussion with the Registered Manager it was confirmed that assessments of resident needs through an individual review had now been undertaken for residents living at the home for several years. The home had actively sought to have resident reviews carried out a representative from the local Social services Department had been involved in these reviews. These reviews were noted to have contained information that was then used to change the care plans of the residents. Documentary evidence was also viewed to show the involvement of residents in these reviews. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for residents to make decisions about their lives are good and make residents feel in control of their own lives. EVIDENCE: The care records seen through the case tracking undertaken on this inspection showed documentary evidence of the involvement of residents in planning their care. Where possible residents signed care plans and with the use of pictures developed a very clear document to tell care staff what they liked to do and what they didn’t and how they could help in assisting them to achieve their individual interests. Daily records were not as comprehensive as the care plans however these were supplemented by further documentation, which contained entries by staff to show for example the activities that the resident had been involved in. A discussion was held with the manager at this visit and it is recommended that all care related documents be kept together in an individual file for each resident. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 10 Through interview feedback from staff and alongside observations made on the care and guidance offered to residents on the day of inspection; supports the conclusion that this standard continues to be met. The scope of risk assessments within the care records of residents included all circumstances under which the resident’s choices were limited. The risk assessments seen reflected and made clear the assessment surrounding this and the reason for the limitation on the resident’s choices; one example was the use of cooking equipment in the kitchen. The way, in which the home approached risk taking for the residents had also changed, the risks that residents wished to take in their lives were supported by the staff team. One resident spoke of going out on their own and how important this was for them. Plans were in place to support and encourage residents in their individual pursuits and if restrictions were in place the reason and consultation with the resident was documented. Decision-making is managed informally due to the small number of residents living at the home. Residents and staff spoke of meeting together to discuss social activities for example. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for activities for residents are good and provide a varied social life for the residents. EVIDENCE: Residents’ support plans gave clear information about how they should be supported to develop and maintain skills, including hopes and aspirations. All residents were engaged in a range of meaningful activities in and out of the home, giving them opportunities to have new experiences and develop skills. Both residents whose care was tracked on this inspection attended Day Service facilities. Within the individual files of the residents’ the inspector saw documents, which listed the varying programmes they attended to assist them in their personal development. All residents had opportunities to participate in the home weekly shop and on the day of inspection all had been out on varying trips and programmes. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 12 One of the residents spoke of how much they enjoyed their attendance at College. Residents’ described the varying activities that they participated in day to day and how they choose what they want to do or where they want to go. On several occasions instances were observed in which all residents had opportunities to be independent in their use of communication, social and living skills. Entries within the care records described the social and leisure activities the residents’ had received. Records viewed on the day of inspection indicated that activities that had been provided for example were shopping trips, walks and going out for a pub meal/drink. The care records seen identified very different individual interests of the residents and they were specific in the identification of their preferred leisure interests, regular contact with family members and visits to their homes were also included. Residents’ informed the inspector of their favourite things that they liked to do and these included for one an interest in music; which they had access to. The home had a weekly menu plan and the inspector saw this. Menus submitted by the home to the Commission for Social Care Inspection were varied and fruit and vegetables were seen to be offered. Meals are taken in the dining area, a brief observation of resident’s having a their evening meal showed that the quantity of food given was good. However no salt or pepper or sauces were offered to any of the residents to flavour their food if they wanted to. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support available to residents in gaining access to healthcare continues to be good with residents benefiting from specialist medical advice and attention. EVIDENCE: Observation of the personal support to residents by staff at this visit showed it to be sensitive and respectful, the guidance and transfer of one resident was seen by the inspector to be explained fully to the resident. Through observation of the residents’ the inspector noted that their clothes, hairstyle and makeup reflected their individual personalities. Guidance and support regarding personal hygiene was offered and the level offered by staff was reflected in the care plans tracked on this inspection. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 14 The residents files tracked on this inspection contained medication profile sheets, these listed all medications past and present that the service user had been prescribed and included dates. Entries on these documents matched the homes medication administration records and the medication stocks for the residents. Storage of all medication was seen to be in a locked cupboard. Healthcare records were also viewed and showed entries for example that residents were weighed when needed. In addition several residents confirmed that they attended hospital appointments all residents are registered with a General Practitioner, documentary evidence of this was seen within the care records. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure in the home continues to be good so resident’s benefit from having an accessible system where they are listened to if dissatisfied. EVIDENCE: As assessed at the homes previous inspection the complaints procedure continued to be clearly on display in the home, this directed the reader in plain terms on how to make a complaint if they were unhappy with anything about the home. The home also had a detailed policy in this area, this gave the necessary guidance to staff on how they should handle a complaint and the actions that they should take if they receive one this included recording the response by the home. Residents when asked agreed that they were aware that they could complain and several knew of the policy on display and its location. All residents said that they would feel comfortable with approaching the staff or manager if they were unhappy. Feedback from resident comment cards all indicated that they were satisfied with the complaints system in the home. No referrals had been made under the local guidance for the protection of vulnerable adults. However a copy of the protocols is kept by the home. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 16 Training records submitted by the home show that staff have also undertaken training in the reporting of suspected abuse. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of cleanliness in the home continues to be good and provides a pleasant environment for the residents to live in. EVIDENCE: All areas seen during the inspection were noted to be clean and free of odours. The home throughout was clean and tidy and scheduled cleaning programmes were in place. Residents who as part of their individual development continue to benefit from taking part in light cleaning duties an example of this is to clean their own individual space with guidance and support from staff. Residents bedrooms contained personal items to assist in creating a homely environment, items seen included photographs and ornaments. Several of the residents spoken with said that they were satisfied with their surroundings; feedback from the residents comment cards also supported this view. The Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 18 standard of furnishings and fittings seen were of a fair standard. One of the bathrooms on the first floor was noted not to have a blind or curtains at the window. This is necessary to ensure the privacy of residents is maintained at all times. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 19 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): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive a good standard of care from a supported and supervised staff group. EVIDENCE: Information regarding training of staff submitted by the manager of the home show that staff had undertaken training in areas including health and safety. Through discussions with staff it was confirmed that they had undertaken a variety of courses including those specifically to better understand the needs of the residents living at the home. In addition staff confirmed that they received regular supervision sessions with management at the home. The Deputy manager had been providing additional support and on call help when the manager was unable to. Staff during this time are able to review their individual work performance and can then with the support of management agree on actions to be taken to improve in their performance, which in turn improves the standard of care within the home. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 20 Examination of staff files was undertaken to look at recruitment practices. It was noted that the files contained proof of identity, verification of employment history and that Criminal Records Bureau clearance had been obtained. Observation of interaction between staff and residents showed that a good amount of conversation took place between them. Residents spoken with felt that most of the staff were supportive to them. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 21 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, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in place within the home for managing health and safety continue to be good and protect the residents. EVIDENCE: The Registered manager of the home has during the year undertaken less on call duties and changed her pattern of working, arrangements for the Deputy to act up in these times was made. On interviewing a staff member they stated that the current management arrangements were “absolutely fine l feel supported”. Residents in the home supported this feeding back that they found both people approachable. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 22 The Manager advised that the home held residents meetings to seek the views of the residents, minutes of these meetings are available for inspection. However she confirmed that the home had not undertaken an annual development plan using the views of residents, thus these results had not been published and made available to the residents and other interested parties. A requirement is made relating to this. Staff and training records showed that they had undertaken training relating to health and safety matters, including fire safety and food hygiene. Fire safety checks were undertaken alongside food temperature checks. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 23 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 3 4 X 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 1 X X 3 X Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 24 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. 2. 3. Standard YA6 YA24 YA39 Regulation 12 & 15 23(2)(d) 24 Requirement Timescale for action 31/01/07 Care plans must always be written in a way that upholds the dignity of all residents. A blind or curtains must be fitted 31/01/07 to the first floor bathroom. A quality assurance system must 31/03/07 be implemented. This must seek the views of service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled and made available to the CSCI. 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 YA6 Good Practice Recommendations The manager should consider setting up individual folders for each resident that would store all care related documents together for that resident. Holly Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Tree Lodge DS0000042607.V321234.R01.S.doc Version 5.2 Page 26 - 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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