CARE HOME ADULTS 18-65
Holly Tree Lodge 122 Spring Road Kempston Bedfordshire MK42 8NB Lead Inspector
Katrina Derbyshire Unannounced Inspection 20th January 2006 14:40 Holly Tree Lodge DS0000042607.V279694.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 Tree Lodge DS0000042607.V279694.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 Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 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.V279694.R01.S.doc Version 5.1 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 5th September 2005 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 12 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 persons, four of whom share double rooms. 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. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 20th January 2006. The Registered Manager Ms. Lorraine Adibi was present throughout the inspection. Many of the areas within Holly Tree Lodge were visited and the inspector spent time with many of the residents’ in the dining and lounge areas of the home. The care of two residents’ was examined in depth by looking at their records and interviewing the residents’ and staff who look after them. Observations of care practice and communication between the residents’ was also made at the inspection. The focus of this inspection was to look at the core standards not assessed at the inspection in October 2005 and to follow up on previous requirements. What the service does well: What has improved since the last inspection?
New dining room chairs have been bought since the last inspection improving this area of the home. The new chairs are modern and comfortable, one resident said, “we got these new chairs and they are much nicer than the old ones”. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 6 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 Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 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.V279694.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Assessment of residents is not to a satisfactory level or frequency to ensure a review of current need is in place for each resident. EVIDENCE: Through examination of documentation within the home and discussion with the Registered Manager it was confirmed that required assessments of residents needs through an individual review had not been undertaken for some time. The home had actively sought to have resident reviews carried out a representative from the local Social services Department had now been appointed, and plans had been made for all residents to receive an individual review by March 2006. These reviews should then directly change if required and be linked to the care plans of all residents. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed at this inspection. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed at this inspection Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 11 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): 18 & 19 The support available to residents in gaining access to healthcare is good with residents benefiting from specialist medical advice and attention. EVIDENCE: Within the individual care records of residents it was noted that there were documents from a variety of medical specialists. These documents showed that residents received regular support from speech therapists, Doctors and Nurses. Staff confirmed that they assisted residents to attend hospital appointments and the outcome of any medical intervention and subsequent guidance was recorded. Residents also spoke of visiting their Doctor; one resident said “if l am not well they always take me to my Doctor”. Observation throughout the inspection was made of the personal support offered to the residents by the staff at the home. At all times this support was given in a respectful and caring manner that maintained the privacy and dignity of the resident. All residents spoken to commented on “how kind” and “very nice” the staff were. Residents also spoke about the manager and how it was in their opinion that she always made sure that they were treated very well and how things had changed for the better since she came to work at the home.
Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 12 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): 22 The complaints procedure in the home is good so resident’s benefit from having an accessible system where they are listened to if dissatisfied. EVIDENCE: The complaints procedure was 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. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 13 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): 28 & 30 The standard of cleanliness in the home is very good and provides a pleasant environment for the residents to live in. EVIDENCE: All areas visited 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 would benefit from taking part in light cleaning duties did so and example of this was to clean their own individual space with guidance and support from staff. The home had purchased new dining room chairs since the previous inspection. The new chairs were domestic in style and assisted in creating a homely environment. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 14 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): 35 & 36 Residents receive a good standard of care from a supported and supervised staff group. EVIDENCE: Staff training records were examined, the manager had been working in this area to make improvements and further work was required to complete this, a discussion with the manager took place regarding this. Staff through discussion confirmed that they had undertaken a variety of training courses including health and safety, food hygiene and workshops to increase their awareness in the specific needs of the residents. In addition staff confirmed that they received regular supervision sessions with management at the home. 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.V279694.R01.S.doc Version 5.1 Page 15 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): 42 Systems in place within the home for managing health and safety are good and protect the residents. EVIDENCE: The homes health and safety policy was examined and was noted to give comprehensive and clear guidance in the main elements of safe practice in the home. Fire safety checks had been carried out and approved contactors had undertaken regular servicing of the equipment, records of all these checks are maintained and available for inspection. Further safety checks are also carried out in the home; examples include testing of water temperatures, food temperatures and risk assessments on all activities and areas in the home. Staff had undertaken training in food hygiene, fire safety and moving and handling. The manager through discussion confirmed that health and safety in the home was discussed at staff meetings to ensure that ongoing reviews and improvements occurred in this area. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 16 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 2 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 3 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 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 3 3 X X X X X X X 3 X Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA2 YA35 Good Practice Recommendations Assessments following a regular review should be undertaken on all residents, this in turn should be directly linked to the care planning in the home. Staff training records should clearly show the training undertaken including dates and duration alongside copies of certification of attendance. Training to be undertaken should also be included. Holly Tree Lodge DS0000042607.V279694.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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