Inspection on 13/08/08 for Holly Tree Lodge Care Home

This inspection was carried out on 13th August 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holly Tree Lodge Care Home 18/03/09

Holly Tree Lodge Care Home 24/08/06

Holly Tree Lodge Care Home 01/12/05

Holly Tree Lodge Care Home 15/12/04

Holly Tree Lodge Care Home 12/07/04

Holly Tree Lodge Care Home 12/01/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Holly Tree Lodge Care Home 3 Eastgate Scotton Gainsborough Lincs DN21 3QR Lead Inspector Doug Tunmore Unannounced Inspection 13th August 2008 09:20 X10015.doc Version 1.40 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 Care Home DS0000034136.V370087.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 Older People. 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 Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Lodge Care Home Address 3 Eastgate Scotton Gainsborough Lincs DN21 3QR 01724 762537 01724 764469 htlcare@btconnect.com 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) Staywood Limited Mrs Pamela Ellen Timmins Care Home 40 Category(ies) of Dementia (17), Dementia - over 65 years of age registration, with number (17), Learning disability (1), Old age, not falling of places within any other category (22), Physical disability (1) Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users in category DE must be aged 50 years and over in Holly Tree Lodge Residential Care Home The bed in Holly Tree Lodge Residential Care Home in category LD is for a service user named in the Notice of Proposal to register dated 21st October 2004 To be able to admit into Holly Tree Lodge Residential Care Home the person of category PD named in Variation Application Number V36870 dated 17th November 2006 No person to be admitted to Holly Tree Lodge Residential Care Home in categories OP, DE, DE(E), LD or PD when 40 persons in total of these categories/combined categories are already accommodated in this home. 24th August 2006 Date of last inspection Brief Description of the Service: Holly Tree Lodge provides nursing and personal care for up to 40 people, 17 of whom who have dementia requiring nursing care and are accommodated in a new purpose built unit. On the day of the inspection there were 35 people living in the home. The purpose built, single storey unit for people with mental illness of old age provides accommodation for 17 people in 15 single bedrooms and one double room. All bedrooms are en-suite with 2 having showers. This unit also has one lounge and one dining room. There is a garden area leading off from the lounge. Accommodation in the main building is on two floors and provides 4 double bedrooms and 15 single bedrooms, none of which have en-suite facilities. Accommodation on the first floor is served by a shaft lift. There are 2 lounges and a dining room. The home is also set in its own grounds. Twenty two people aged 65 years and over who require nursing care or personal care and one person aged 55 years who has a learning disability are accommodated in the main building. There are car parking spaces at the front of the home. The fees at the inspection visit on the 13/08/2008 ranged from £351:00 to £740:00 each week. Extras are for hairdressing, chiropody, personal newspapers and magazines. The provider makes no charge for escorting residents to hospital. Information about the home can be obtained from the Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 5 manager of the home. The service user’s guide is available from the manager and is kept in the office. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use this service experience poor quality outcomes. One inspector who was accompanied by an expert by experience undertook this visit to the home. This formed part of an unannounced key inspection. This visit took into account any previous information held by The Commission for Social Care Inspection (commission) including the homes previous inspection reports and the homes Annual Quality Assurance Assessment form, hereafter in this report referred to as AQAA. ‘Have Your Say’ surveys were sent to the home by the commission and residents returned three, which were completed with help from relatives and visitors also returned three surveys. The site inspection consisted of case tracking a sample of two residents records and assessing their care. The expert by experience spoke with three residents, two visitors, one carer and the nurse in charge of the elderly mentally infirm unit (EMI). The inspector spent time with two senior nurses, the administrator, the cook, two carers and the maintenance man. The inspector also met with a visiting community psychiatric nurse. Observations were made throughout this inspection of the relationships between people who live in the home and carers. The manager was unavailable for this inspection. A partial tour of the home and a review of a sample of the records were also included. What the service does well: The home provides good information to prospective residents and relatives to help them make informed choices, and they are assured that the home can meet their needs through a comprehensive assessment process. Residents benefit from comprehensive care plans and access to a range of healthcare professionals. They enjoy a balanced diet based on their likes, dislikes and choices and benefit from a comfortable and hygienic environment that meets their individual needs. Comments made by one resident who is on permanent bed rest were, ‘the girls (staff) are very nice, they never grumble and they turn me when required and give me liquids and meals all the time. They are very careful when they wash me and are careful about my privacy and dignity’. Surveys received from Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 7 people who live here and visitors were positive confirming that the care staff are professional and provide the care that residents require. Those residents who spoke to the expert by experience said they were frequently asked if they were ‘ok’ , had no problems with the laundry service or the staffing. ‘All the ‘girls’ (staff) are very ‘kind and considerate’. What has improved since the last inspection? What they could do better: 1. Care plans must address the issues of individual residents privacy and dignity and how this is to be delivered. This would ensure that individual residents have their say as to how their privacy and dignity is to be maintained, given the daily routines that communal living imposes on them. 2. All files must contain a six monthly review form, detailing any changes that might have been made in the care plan regarding the care to be delivered. This ensures that all staff are aware of the needs of all residents. 3. Two personnel files of workers at this home were seen not to have the appropriate documentation required to help ensure the safety of those people who live in this establishment. All workers must have the required criminal record bureau checks before commencing employment at the home. 4. There has clearly been a systems failure both within the management of the home and in the monitoring of the home by the providers. Regulation 26 reports undertaken monthly and supplied to the commission need to reflect on current recruitment procedures. 5. The provider is advised that all care plans need to incorporate principles of the Mental Capacity Act 2005, in relation to the ability of residents to make judgements about the care they wish to receive. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 8 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 Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 Standard 6 is not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive information about the home, which helps them to make an informed decision about where to live. The clear assessment process assures them that their needs can be met within the home. EVIDENCE: The providers AQAA states that; ‘Pre-assessment is carried out by Matron, meeting with proposed resident/family. Multi disciplinary meetings, if possible with Social workers, Community Psychiatric Nurses and GP’s. Discussion with staff to make sure we can meet the resident’s needs’. All three surveys received from people who live at the home confirmed that they received information about this home prior to admission, enabling them to decide if it was the right place for them. One specific comment was, ‘we Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 11 came and viewed the home and was told all information needed, also had lots of information from other people who had relatives already here and read reports about the home too’. Three surveys from visitors confirmed that the care home meets the needs of their relative. A review of all information available prior to this inspection and evidence seen at this inspection in residents files and care plans showed that the home does not admit residents without a care assessment being undertaken. Prospective residents are also written to by the provider confirming whether they can meet the residents care needs or not. There was also evidence of hospital needs assessment, which are kept in resident’s files. The administrator confirmed that there has been no change since the last inspection and all residents either have local authority contracts and or the providers terms and conditions. There are no intermediate care services provided at the home. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare needs are met so as to ensure their wellbeing. An accurate record is made of all medication given to people so as to ensure their wellbeing. The care planning systems do not ensure that resident’s privacy and dignity is maintained. EVIDENCE: The providers AQAA states that;‘ we have a person centred approach to care of residents, both physically and mentally. Completed care plan is the tool we work towards, to give the best possible care, to meet the needs of the individuals; care plans include physical and mental needs of residents. All staff are instructed in the 7 core values of care. Ongoing instruction at staff meetings and observation keep us aware of the residents right to privacy’. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 13 Those surveys received confirmed that people felt that they receive the care and support, including the medical support they need. A specific comment made was, ‘I always received best support available’. Two visitors surveys showed that the care home met the needs of their relative, always and one felt their needs were usually met. A comment made was, ‘we are always made aware if anything is wrong and get medical support when needed’. Two carers stated at this visit that they were aware of safeguarding peoples dignity and privacy, whilst undertaking their intimate care needs. Two files of residents who were being case tracked were seen. Records did not evidence that residents had been involved in determining that their individual intimate care needs are being addressed in their care plans, for the information of carers. The expert by experience spent most of this visit in the EMI unit observing the daily routine of those people who live there. She found that people were spoken to by staff members with dignity and respect and she was especially impressed by the calmness of the carers dealing with difficult situations. A previous visit undertaken on the 24/08/06 showed that daily records written by staff were clear and records show that people have access to health care professionals. Files also evidenced that care plans had been developed to show residents daily routines and included separate risk assessments, which showed how assessed physical risks were being managed together with each resident. Risk assessments were clearly recorded and easy to understand. We looked at one residents file who was being case tracked and found that it did not contain a six monthly review form detailing any changes that might have been made in the care plan regarding the care to be delivered. Visitors stated to the expert by experience that if they felt the need of adding to the care plan they would make sure it was seen to by way of the nurse in charge. A visiting Community Psychiatric Nurse (CPN) commented that communication between nurses at the home and CPN could be improved. She also said that there were no concerns about the care delivery to the people who live in the home. We looked at resident’s medication sheets were seen and it was found that an accurate record is kept. The senior nurse on duty confirmed that no residents are able to self medicate; she also stated that only nurses give medication to residents. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 14 The homes training plan showed that nurses had undertaken medication training (distance learning) in April 2007-8. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a varied and appropriate activity programme, which enables them to maintain an active social life. They are able to choose from a range of foods within a balanced diet. EVIDENCE: The providers AQAA evidences that ‘all residents have absolute choice of where and when they eat, also a choice of time of rising and retiring. We have an open policy for family and friends, they are welcome to stay for lunch/tea and overnight if necessary, due to illness Social activities are geared to individual choice. Documented in activities diary and on public notices. All residents asked their preferred hobby and likes/dislikes, i.e. gardening, music, games etc. Dementia sufferers family involvement sometimes required. Activities to suit, by use of smells and tactile activities, which help the residents suffering sensory difficulties’. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 16 Specific comments made in residents surveys were; yes activities are arranged and I usually take part. Another comment made was that ‘there are not enough outings, visits to the ice cream park, beauty spots or garden centres’. Two of the three surveys showed that the residents always liked their meals and one usually did. One commented that ‘the meals are all nice, home cooked and cater for my needs’. Comments made in visitors surveys were, ‘they care for my mum. Nothing is too much trouble for the staff. I am always made welcome’. Another visitor stated that, ‘there is a homely, pleasant atmosphere about the home, which is of course created by hard working staff’. Evidence was seen at this visit in the activities notice placed in the entrance to the home that a variety of activities and outings take place. Activities arranged for August, September and October my the manager included crafts, ball games, bingo, barbeque, trip to Cleethorpes in which ten residents went three of whom were from the dementia unit. There is a visiting craft worker and a ‘motivation lady’ who visits to undertake projects with residents. Religious holidays are also celebrated and visitors are encouraged to join in. Two carers stated that activities are usually undertaken in the afternoon when they have more time and today those residents who wish to can play dominoes. One resident commented to the expert by experience that she was able to choose her own clothes and dress herself smartly. She confirmed that she is able to use her call bell and able to express her dislike of things. The resident also expressed her liking for outings and said she liked to go outside into the garden and plant the planters. Two other residents confirmed that their religious needs were met by way of a vicar who visits from time to time. The inspector joined residents for lunch and was informed that they enjoyed the food. The expert by experience found that staff, were sensitive to the residents needs i.e. offering more gravy & drinks throughout the meal. Residents & relatives spoken with said that all the meals were ‘lovely and plentiful with ‘homemade puddings’ If the menu was not to their liking an alternative was on offer. The food appeared of good quality and plentiful. The home has again been awarded a Food Safety Award. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Policies and procedures for addressing and monitoring complaints and concerns are in place to protect residents who are vulnerable. Residents are placed at risk due to inadequate procedures in the employment of new staff. There has clearly been a systems failure both within the management of the home and in the monitoring of the home by the providers. EVIDENCE: The providers AQAA confirms that ‘all are staff instructed on procedure for complaints. Complaints procedure is posted around the home. All staff are instructed on induction to the various forms of abuse On admission, Matron advises the resident/family of the procedure which is also in the brochure given to them. External training sessions instructs with regard to Adult Protection issues. Criminal Record Bureau Checks and Protection Of Vulnerable Adults checks done on new staff’. All surveys showed that they the relatives and residents know how to make a complaint and no concerns were raised. Two visitors told the expert by experience that they knew who to complain to and have nothing but praise for the staff. ‘Care is A1, could never be better anywhere else’ Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 18 A resident told the expert by experience that, ‘I know who to make a complaint to if necessary and wouldn’t hesitate’. Other residents spoken with said they felt safe, secure and private. Previous inspections of this home have shown that a detailed complaints procedure is in place. The homes complaints AQAA recorded that two complaints had been made in the last year, both of which have been resolved. Resident’s questionnaires showed that they were aware of how to make a complaint and knew who to speak to if they were unhappy. We looked at two personnel files of staff employed on the 27/04/08 and 02/07/08. Both were working at the home at the time of this visit. It was found that neither had received a Protection of Vulnerable Adults check (POVA) and neither has had a Criminal Record Bureau check (CRB). The administrator was consulted about this omission to carryout appropriate checks and confirmed that they had not been undertaken. The operations director was contacted by the inspector and was advised of two workers without appropriate regulatory checks. The operations director immediately asked a senior nurse to inform these workers that they are presently unable to work until this matter is resolved. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in clean, well-decorated, homely and safe accommodation. EVIDENCE: The providers AQAA confirms that, ‘a program of maintenance to make sure all areas are kept clean, tidy and safe and two cleaners and a laundry assistant work daily to provide a clean and well maintained home. There is an enthusiastic well motivated maintenance person’. All surveys show that the home is kept clean and tidy and there are no unpleasant odours. A visiting Community Psychiatric Nurse confirmed that she is a regular visitor during and during her visits she had not detected any unpleasant odours. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 20 The maintenance man was decorating a bedroom at the time of the visit and confirmed that there is a rolling programme of refurbishment. He also stated that he has a maintenance book in which repairs are recorded. The expert by experience found the EMI unit to be clean, comfortable, light, airy, clutter and odour free. The resident’s lounge was newly carpeted very nicely decorated with appropriate pictures and a calendar clock on the walls. The patio doors in the lounge open onto a small secure enclosed garden where She was told that residents who are able are encouraged to wonder in and out freely, under supervision, weather permitting. Residence told the expert by experience that they are more than happy with the environment and feel safe and secure at night. The files were seen of two people who were being case tracked and who were either confined to their bed or used aids and adaptations to help maintain their independence. It was found that risk assessments were available for the use of bedrails and wheelchairs strap and back wedges. Information was also available for staff on how to use this apparatus safely. One resident stated that the bedrails are very good and stop her from falling out of bed. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a knowledgeable staff team who are well trained. EVIDENCE: The providers AQAA evidenced that, ‘Staff rota reflects skill and mix of staff with regard to experience, NVQ2, NVQ3. Staff also allocated to preferred place of work, either Dementia or Nursing and residential. All staff have access to paid training days, internal and external and as many as we can fit in staff levels reflect in resident numbers or dependency, using extra staff at peak times and additional kitchen staff at tea time. Trained nurses on duty 24 hours a day, two during the hours of 7am to 9pm’. Resident’s surveys show that they feel that they receive the care and support that they need. All relatives surveys indicated that the care service support people to live the life that they choose. Previous visits made on the 24/08/06 found that the manager had given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults, to all carers as part of their induction training. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 22 The training profile was seen and showed that seven care staff are trained to NVQ level and two workers training to NVQ level 2 and 3. Two carers are currently undertaking NVQ training (National Vocational Qualifications). Care workers confirmed that they had undertaken the following training; health and safety, managing challenging behaviour, moving and handling, safeguarding vulnerable adults, food hygiene and one had undertaken infection control. One cleaner was seen and stated that she started work in February 2008 and had not undertaken infection control training. The homes duty rota was seen and it was found to be an accurate record and showed that adequate staffing levels are maintained to meet the needs of residents. There is one nurse waking night staff and three carers. The CPN commented that she did not see carers around when she visits and added that it is a big home and she usually talks to the senior nurse on duty. Two care staff confirmed that they felt that there were enough staff on duty and that ‘there is a good mix of staffing abilities with those who are not qualified working with senior carers ‘. Another comment was that ‘this is a good home to work in with good staff relationships’. During the day of the inspection staff were observed carrying out their duties in a sensitive and caring manner. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s valuables are protected due to adequate procedures. The home is well managed meeting the needs of residents whose health, and welfare are protected, however, monitoring of the service is not sufficiently robust to ensure the safety of residents. EVIDENCE: The Providers AQAA states that ‘6 monthly Quality Assurance questionnaire sent to a of residents/families. Most residents prefer their money to be kept in the safe in the office. All residents have a lockable facility in their room Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 24 All residents, on admission, are assessed for mobility needs, i.e. Hoist, Stand Aid, and Moving and Handling belt Manager is constantly involved with all aspects of care and housekeeping. Good Quality Assurances responses and general comments lead to good reputation. Endeavour to have residents meeting to ascertain their feelings’ The registered manager is qualified and experienced in running this home for older people. The operations manager visits the home on a monthly basis and undertakes an audit, with a copy of the report being sent to the commission. Staff made positive comments regarding the manager, with one stating that; ‘she is very nice easy to approach, she listens to concerns of staff and spends time on the shop floor’. The expert by experience found that relatives are very aware of the structure of the management team and feel very happy with the input from the manager and feel they have a very approachable relationship with her. All relatives praise the deputy manager. The home conducts an in house quality assurance (QA) report. The quality assurance report is posted in the entrance hall for the information of residents and visitors. A sample of the homes internal audit was seen and showed that comments were positive in respect to the care provided to residents. We looked at one person’s valuables form, which showed that a record had been made of clothing brought into the home. There was also a photograph on file to identify the resident’s valuables. The last residents/visitors meeting was held on the 23/01/08; there was a small attendance and no concerns were raised. The providers AQAA showed that; gas safety inspections have been carried out, electrical wiring checks, fire precautions checks, and portable electrical equipment checks. The manager stated that risk assessments are available relating to the home environment. Staff had been trained in Health & Safety, Fire procedures, etc. Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 26 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. Standard OP7 Regulation 15(2)(b) Requirement A system must be established to ensure that all reviews are recorded and are made available on resident’s files for the information of carers. A system must be established to ensure that individual residents privacy and dignity is recorded and acted upon. A system must be established to ensure that the provider’s recruitment processes protect residents. Timescale for action 16/10/08 2. OP10 12(4) (a) 16/10/08 3. OP18 19(1) Schedule 2(3) 13/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holly Tree Lodge Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Care Home DS0000034136.V370087.R01.S.doc Version 5.2 Page 28 - 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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