Inspection on 06/11/08 for Holly Tree Lodge

This inspection was carried out on 6th November 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Tree Lodge 11/12/06

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

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Paradise Lodge

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Upaya Ananda

Newton Court (1-2)

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Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Holly Tree Lodge 122 Spring Road Kempston Bedfordshire MK42 8NB The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Neil Fernando Date: 0 6 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 30 Care Homes for Adults (18-65 years) Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Holly Tree Lodge 122 Spring Road Kempston Bedfordshire MK42 8NB 01234266391 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : adal361@aol.com Dr Saravanamuttu Sivapalan,Mrs Sarojini Sivapalan care home 14 Number of places (if applicable): Under 65 Over 65 14 0 learning disability Additional conditions: 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. Up to 7 service users may also be over the age of 65 years The manager must complete an NVQ 4 in care by 31 December 2005. Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 30 A bit about the care home 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 been refurbished. The shower on the ground floor has also been adapted for use by people with physical disabilities. A copy of the last inspection report from the Commission for Social Care Inspection is available at the home, for residents and visitors to read. The fees for this home vary between £500 and £1050, depending on the funding source and individual needs of the residents. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 30 How we did our inspection: This is what the inspector did when they were at the care home The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We, the Commission for Social Care Inspection, undertook this unannounced key inspection on 6 November 2008. We spoke with 3 residents, the manager and 3 staff including a senior member. We spent a significant amount of time discretely observing residents and staff care practices. We had a look round the accommodation and viewed a range of records the home must keep. At the time of the visit, there were 9 residents accommodated with 2 vacancies. The completed AQAA (Annual Quality Assurance Assessment - a document, which gives the manager the opportunity to tell us how well outcomes are being met for people living in the home) has been received; it provides comprehensive details about the service. We have also received surveys from 5 residents and 7 staff. The manager was present throughout the inspection. An annual service review was carried out on 19 March 2008. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well Residents expressed a high degree of satisfaction with respect to the quality of care and support they receive. Their views including those of staff have been included in the report. Good assessments are carried out before people are admitted to the home. Care plans are comprehensive and the annual review system ensures that the residents identified needs are addressed and unmet needs, closely monitored. A high level of social and recreational activities to suit the taste and preferences of residents are being facilitated; thus maintaining a good level of stimulation. Relationships between the staff and the residents were positive. Staff appeared committed and they demonstrated a thorough awareness of the identified needs of each resident including equality and diversity issues. We saw that staff were very polite, helpful and caring towards the residents. The meals provided are of a good quality and residents like them. Menu planning takes place weekly and residents taste and preferences are well catered for. The training needs and future development of staff are being identified and addressed. NVQ training for staff is being given a high profile; staff are therefore well equipped with the skills and Care Homes for Adults (18-65 years) Page 8 of 30 knowledge to provide a good quality service for residents. Care and staff management systems are being implemented to good effect. 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. What has got better from the last inspection There were 3 requirements and 1 recommendation made in the last inspection report dated 11 December 2006. Their implementation have resulted in an improved quality of service for residents. The views of the people who use the service, their representatives and significant others are sought in a number of ways including participation in self assessment, care plan reviews, annual surveys and through choice and decision making processes. Most of the written documents known as care plans are clear to both residents and staff in the support that each resident needs. All care plans use pictures and words to help with this. Evidence shows that care plans are now written in a way that is respectful and upholds the dignity of the resident. A blind has been fitted to the first floor Care Homes for Adults (18-65 years) Page 9 of 30 bathroom, in order to ensure the privacy and dignity of residents. Individual folders have been set up for each resident; this ensures that all care related documents are kept together for that resident and any required information, easily retrievable. The home has continued to improve and maintain good standards of care. What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home Care Homes for Adults (18-65 years) Page 10 of 30 If you want to speak to the inspector please contact Neil Fernando 33 Greycoat Street London SW1P 2QF 02079792000 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 11 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 12 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home makes sure it can meet peoples needs by getting detailed information about them before they are offered a place. Evidence: The statement of purpose and service users guide have been reviewed and updated by the manager. These are in writing and in pictorial form, which makes it very user friendly for residents, in particular. The AQAA indicates that all prospective residents have a full individual assessment completed by a social worker from the placing authority, prior to a placement being identified. The needs of the resident are taken into account before a placement is agreed or offered. All of the nine residents have been accommodated at Holly Tree Lodge for a number of years; indeed, there have been no new admission to the home in the last couple of years. Care files for three people show that when the home receives a new referral, a detailed assessment of needs is completed involving the manager, potential resident, family, the social worker and significant others. The manager and staff members said that the prospective resident and their family Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: have the opportunity to visit the home for a cup of tea, a meal or over night stays as necessary, to enable them decide if the home is suitable to their needs. I visited many times before moving in, said one resident. Staff members spoken to said that they would help the prospective resident decide if the home is suitable for them. Overall, good evidence is available to show that the home is careful to only offer a place to the resident whose needs and aspirations it can meet. The terms and conditions are both in writing and in pictorial form; a copy of the agreement is kept in individuals files, which include the signature of the resident and their representatives. This is to ensure the rights of people living at the home are being upheld. Care Homes for Adults (18-65 years) Page 14 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . A detailed care plan setting achievable targets together with a system to review the care for each resident are in place; thus ensuring that identified needs are addressed and unmet needs, closely monitored. Evidence: Three of the residents care files were viewed. Detailed information and guidelines are recorded for the delivery of care and support required so that assessed needs can be safely met. Daily care notes are also detailed and accurately recorded. The residents care plan is drawn up from a range of assessment of needs including the resident, social workers reports, input from family, staff on going assessment and contributions from other professionals. The care plans for three residents were examined; each person has a detailed care plan, which identifies how their individual needs would be met. The information had been kept up to date and reflected the support being provided. We are always kept up to date with any changes in the care plan for the resident, said one staff member. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The three care records seen through the case tracking undertaken on this inspection provide evidence of the involvement of residents in planning their care. Where possible, residents sign their care plans and with the use of pictures have developed a very clear document to tell staff what they like to do and what they do not. This assist residents with communication difficulties to make choices about their lives for example: food, social and recreational activities, culture and religion and other individual interests. Three residents attend the local church on a regular basis. Records show that all the residents bar one have had their annual reviews completed for this year. The manager said that she was in the process of arranging for the outstanding review to be carried out before the end of December 2008. The scope of risk assessments includes all circumstances under which the residents choices are limited. The risk assessments seen reflect and make clear the assessment surrounding this and the reason for the limitation on the residents choices; one example is the use of cooking equipment in the kitchen. Care Homes for Adults (18-65 years) Page 16 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The residents are pro actively encouraged to make choices for their activities, and to be involved according to their abilities, in developing their skills for independence. This enables them to live a fulfilling life. Evidence: Residents care plans provide clear information about how they should be supported to develop and maintain skills, including hopes and aspirations. All residents are engaged in a range of meaningful activities in and out of the home, giving them opportunities to have new experiences and develop skills. Care files examined for three residents provide evidence of the varying programmes they attend to promote their personal development. They have excellent opportunities to participate in a range of social and recreational activities to maintain a good level of stimulation. On the day of the inspection, all residents had been involved in some form of activities either in the home or out in the community. The three residents spoken Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: with described the varying activities that they participate in daily and how they choose what they want to do or where they want to go. I have a weekly activities I have chosen for me, said one resident. Activities, which occur regularly include local events, theatre, visits to the local pubs, clubs and entertainment venues, shopping for food and clothing. Individuals follow their own routines as appropriate. All residents attend Day Service facilities during weekdays. Two residents attend college and one does voluntary work. Some residents also have day or overnight stay with their families. Induction training for staff and recruitment policy encourages equality and diversity. Residents are encouraged and they are able to practice their religion, sexual preference and their culture, as appropriate. There are currently three residents who attend the local church with some assistance from staff members. Residents are encouraged to maintain meaningful relationship with their families,friends and peers. Visiting times are flexible and families and friends are welcomed. Staff were clear that residents would be respected and treated with dignity and respect at all times. Residents are fully involved in the choices of food in the home and a weekly menu is organised. Choices are clearly offered and snacks and drinks are available throughout the day. Residents dietary needs are being met and healthy eating habit is promoted. Residents are supported and encouraged to be involved in cleaning their rooms and other domestic chores including laundry, food preparation and washing up. Care Homes for Adults (18-65 years) Page 18 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Care plans and daily records show that the identified health and personal care needs of residents are being addressed in a manner that ensures their well being. Evidence: The care plans for three residents were viewed and they provide comprehensive details of each persons personal and health care needs. Their preferences about how they wish to be supported are also included in the plan. Detailed recording of each persons health care includes health notes for hospital visits and contact with the GP and other health professionals. The home has satisfactory policy and procedure in place that ensures the safe receipt, administration and disposal of medication. Medication is safely stored in three locked cabinets, including a trolley. Records indicate that staff receive training on medication before they are allowed to administer medication to people using the service. Care staff spoken to all appeared knowledgeable about ordering and disposal of medicines. I administer medicines to residents according to the home procedure on medicines, said one staff. The MAR (Medication Administration Record) sheets are used to record any medication Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: administered. The administration records were examined for all nine residents and these were found to be in order. Three residents reported that they Always receive their medicines on time. Risk assessments are in place and are reviewed at regular intervals. Daily audits of medicines are carried out by a senior care staff or the manager, in order to ensure safety for both residents and staff members. Care notes viewed show that changes in needs as people age are being taken into account. The transition is still in line with meeting the residents needs that best address their ongoing requirements. There was a relaxed atmosphere throughout this home. We observed a good relationship between the staff and the residents; staff interaction with residents was supportive, friendly and respectful. Care Homes for Adults (18-65 years) Page 20 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents are encouraged to contribute their views and feelings on all aspects of daily life in the home. There is a robust and effective policy and procedure in place to protect them from harm. Evidence: The home has a clear complaints procedure to ensure that any concerns are dealt with speedily and satisfactorily. All residents spoken with felt able to raise any concerns they may have about the service. I would speak with my key worker, said one resident. Surveys from five residents indicate that they know how to make a complaint. Complaints record indicates that the home has not received any complaints since the last inspection in December 2006. The Commission for Social Care Inspection has also not received any complaints regarding Holly Tree Lodge. The policy and procedure regarding safeguarding adults is available and accessible to the staff team. This has been updated to provide the procedure in writing and in pictorial form. Discussions with staff members provide evidence that they would have no hesitation in reporting any incidents of abuse or neglect to the manager or a senior staff member on duty. Information gained from training records and three staff members spoken to, indicates that all members have received training in Safeguarding Adults. It was noted during the inspection that care staff spoke to residents in a friendly, social and respectful manner. Care Homes for Adults (18-65 years) Page 21 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of 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: The accommodation offers good size bedrooms to each resident. All bedrooms are well personalised to reflect the taste and interest of the occupants with gadgets, pictures and hobby materials. Furniture and fittings in all areas viewed including the dining area are of a domestic type and of a fair standard. There is evidence to indicate that residents are given a key to their bedroom where appropriate. Staff interviewed said that residents privacy is upheld at all times; We would always knock before entering bedrooms, said a member. 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 members. The standard of cleanliness throughout those ares viewed was good. The only maintenance work identified includes redecoration of the lobby area near the kitchen. The manager is aware of this shortfall and said that this would be addressed, in order to promote a more homely atmosphere. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: Residents spoken with said that they are satisfied with their surroundings; feedback from the residents surveys also supports this view. Care Homes for Adults (18-65 years) Page 23 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The homes recruitment processes are robust, which means that residents are protected from harm. Accessing appropriate training ensures that staff are competent to deliver good quality care to residents. Evidence: The duty rota for a period of three weeks showed that there are adequate numbers of staff available at all times to meet the needs of the resident group. Staff spoken to said that There is good staff cover at all times and the manager and supervisor are available on call, as needed. In terms of skill mix, the staffing arrangements are appropriate to ensure that the needs of the people in residence could be met. Staff receive induction that covers mandatory health and safety training. Records and information from staff show that a very good level of training is being provided on a wide range of subjects. The AQAA indicates that training received by staff includes diabetes, makaton, first aid, fire training and health & Safety. All staff members are currently undertaking a 16 week course in a recognised certificate in dementia at a local college. The manager said that new members complete Skills for Care Foundation units including Learning Disability units. With the length of employment and training courses, I feel I have the right support, experience and knowledge to deal with clients and their needs, reported one staff in their survey. Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: The personnel recruitment files for 3 staff including the last member who joined the team were scrutinised. They provide evidence that various checks including Criminal Records Bureau checks and references had been undertaken as required by The Care Homes Regulations 2001. It was however noted that a recent photograph must be added to all the staff files seen. The manager is aware that this must be addressed Of the current 12 care staff 7 hold an NVQ level 2 or equivalent in care, 3 are working towards it and 1 member has a Diploma in Social Care. This means that the home has already achieved a ratio of 66.6 of staff with NVQ Level 2 or equivalent, which is above the minimum standard. Evidence of recorded supervision sessions are available in staff files. 3 care staff members spoken with confirmed that they receive formal 1 to 1 supervision every 6 to 8 weeks. Care Homes for Adults (18-65 years) Page 25 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The manager provides good support and guidance to the staff team; this ensures residents receive good quality care. Evidence: The registered manager has worked at this home for four years and she has significant management experience. She holds an NVQ level 4 in management and the Registered Managers Award. The owner is in the process of recruiting a deputy manager with an NVQ level 4 in care and management. Staff spoken with were complimentary regarding the support they received from her. They stated that they find the manager very approachable and supportive. This home is run to make sure clients and staff are happy under the manager, said a staff. There are robust policies and procedures in place, which are being implemented to good effect. Staff spoken with and training records viewed show that staff have undertaken training relating to health and safety matters, including fire safety and food hygiene. Fire safety checks are undertaken alongside hot water and food temperature checks. Fire drills and weekly tests of break glass points are carried out regularly and satisfactory records are maintained. Other records viewed were noted to Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: be in order. The owner meets with the manager at the home weekly to discuss her supervisory needs and other operational matters. The owner also prepares a monthly report, in order to ensure appropriate standards are being maintained; reports on the visits for the months between August and October 2008 were viewed and noted to be satisfactory. A formal quality monitoring system (form of annual surveys), based on seeking the views of residents, relatives and other stakeholders, in order to improve the quality of its service for residents has been introduced. The manager was in the process of compiling information gained from a survey carried out in October 2008. The manager is aware that the results of surveys should be published and made available to residents, representatives and other stakeholders, including the Commission. There is good evidence to demonstrate that residents are well cared for; all those spoken with expressed a high level of satisfaction with respect to the care and support they receive at Holly Tree Lodge. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 30 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 24 23 10/01/2009 The lobby area near the kitchen must be redecorated. This will ensure a more domestic atmosphere. 2 34 17 Staff files must include a 20/12/2008 recent photograph as detailed in Schedule 2 of the Care Homes Regulations 2001. This will ensure the protection of residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 30 of 30 - 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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