Inspection on 20/05/09 for Holly Tree Lodge Residential Care Home

This inspection was carried out on 20th May 2009.

CQC found this care home to be providing an Adequate service.

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

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Holly Tree Lodge Residential Care Home 2 Thornhill Road Derby Derbyshire DE22 3LX Lead Inspector Angela Kennedy Key Unannounced Inspection 20th May 2009 10:15 DS0000073088.V375560.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Lodge Residential Care Home Address 2 Thornhill Road Derby Derbyshire DE22 3LX 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) 01332 382660 01332 382671 Holly Tree Lodge Ltd Patricia Irene Allsop Care Home 27 Category(ies) of Dementia - over 65 years of age (27) registration, with number of places Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia over 65 years - code DE(E) The maximum number of service users who can be accommodated is 27 New service 2. Date of last inspection Brief Description of the Service: Holly Tree Lodge is a 27 bedded home for people of both sexes aged 65 years and over who have dementia. Holly Tree Lodge was originally a private dwelling that has been extended on several occasions. The home is located in a residential suburb of Derby, close to several main routes into the city. The home has two storeys, and accommodation is located on both floors, whilst lounge and dining areas are on the ground floor only. Holly Tree Lodge has five shared rooms, one of which has ensuite facilities, and 17 single rooms, a number of which have ensuite facilities. Residents have access to a wellmaintained garden area. The fees at the time of this inspection ranged from the Local Authority rate for people that were funded to £394 a week for those that were privately funded. Items not covered by the weekly fee included; toiletries, chiropody, hairdressing, dental treatment, clothing and transport and staff escorts to hospital appointments. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This is the first key inspection of the service since its registration with Holly Tree Lodge Limited, who are the new providers of this home. This key inspection was unannounced and took place over eight hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. An Annual Quality Assurance Assessment (AQAA) had been completed by the service. This is a self-assessment for provider’s that is a legal requirement. This assessment gives the provider an opportunity to let us know about their service and how well they think they are performing. The information provided in the AQAA is reflected within this report. Two people were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at support plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Discussions with the people living at the home were limited to a few people, as many where unable to express their views. Those that were able to express their views were spoken with and two surveys were returned from people living at the home. The comments received in the surveys and on the day of the inspection visit are included within this report. Two relatives were spoken with on the day of this inspection visit and three surveys were returned from relatives or friends of the people living at the home. The information provided in discussions and from the surveys are included in this report. Some of the staff team were spoken with to gain their views on the service and support provided to the people using the service and the training and support Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 6 given to staff and two staff surveys were returned. The comments from discussions and within the surveys are reflected within this report. The deputy manager was available throughout the inspection. What the service does well: A revised statement of purpose and service user guide has been provided since the new registration of the home, this was seen and ensured that those considering the service and those already using the service will have up to date information which sets out the new provider’s details and includes the required information. A full pre admission assessment was undertaken for each person before admission was agreed, to ensure the home was right for them. Care plans were then developed from this assessment to ensure people were supported appropriately and their needs were met. Observations of staff with people living at the home were positive and demonstrate a relaxed atmosphere with a good rapport between the staff and the people using the service Staff spoken with on the day of this inspection visit said the communication between the staff was good, they felt they worked well together as a team to ensure people’s needs were met Comments received from relatives included ‘the staff are friendly and contact us if there are issues with mum’ and ‘the care seems good’ and “The staff at the care home have always given mum plenty of fuss and attention to her every need.” What has improved since the last inspection? What they could do better: A thermometer was in place to record the temperature of the clinical fridge but this did not record the minimum and maximum fridge temperatures to check the clinical fridge was running at the correct temperature. The record sheet showed that the temperatures for the clinical fridge had not been recorded for Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 7 two days, therefore had the fridge not been working correctly this may not have been noticed and could have affected the medication stored in it. Further improvements are needed for exit from the conservatory to the garden area, as there is small step that is not suitable for the less mobile person or someone that uses a wheelchair. A handrail has been fitted outside the French doors that lead to the garden but this was blocked by the door when open, so making this handrail inaccessible. Staff recruitment files seen did not have full employment histories recorded on their application forms. This is needed to enable the employer to clearly identify any gaps in employment that needed to be explored. One of the staff files looked at did not have a reference from their last employer. The provider’s self assessment indicates that not all equipment and appliances at the home had been serviced as required. This was further assessed at the inspection visit. The 5 year electrical re wiring certificate was no longer valid. This had expired in March 2009. The Fire Fighting equipment had not been serviced since February 2008. Records demonstrated that the emergency lighting within the home was last tested in September 2008. The records showed that the Gas appliances within the home had not been serviced since March 2008. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 8 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 Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs were assessed before admission was agreed to ensure the home was right for them. EVIDENCE: The provider’s self assessment stated that all relevant information is provided to people considering the service and their relatives prior to admission. A revised statement of purpose and service user guide has been provided, this was seen and ensured that those considering the service and those already using the service will have up to date information which sets out the new provider’s details and includes the required information. Information provided by the manager prior to this visit stated that people considering the service are invited to view Holly Tree Lodge and stay for lunch Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 10 if they wish to, they are invited to tour the home and ask questions and meet other people that live there and staff. The manager stated that she never arranged appointments for viewing but asked people to come whenever they wished. Visitors spoken with confirmed that they were able to view the home without making an appointment. This demonstrates that the home is run in an open and transparent way. Information provided by the manager prior to this visit stated that she or the deputy manager undertakes a full pre admission assessment, this can be in the persons own home, hospital or any location to fit with the person’s current situation. When a person is funded by local authority a care plan is always requested prior to admission, from this information and the homes own assessment a decision is made by the home manager if their needs can be met as set out in Statement of Purpose. An admission date is agreed with all parties involved and an individual care plan is written from the information gained from the pre admission assessment. Both individuals care files seen had a completed needs assessment in place that addressed their social, emotional and health care needs. This included an assessment in place from their care manager. The care plans seen demonstrated that this information was then used to develop the care plans for each person. Information within the surveys received also confirmed that individuals or their representatives had received a contract of residency and that they had received information prior to admission to enable them to make an informed choice about the home. Staff surveys also confirmed that all the relevant information for each person was recorded in their care plans to enable them to support people effectively. Staff spoken with on the day of this inspection visit said the communication between the staff was good, they felt they worked well together as a team to ensure people’s needs were met. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual’s support needs were set out within their plan of care and demonstrated that health care needs were met. The medication practices in place ensured that people were able to take their medication as prescribed. EVIDENCE: As confirmed in the provider’s self assessment each person living at the home had an individual care plan and risk assessments in place. Care plans set out the action required by staff to meet each persons’ needs and were reviewed monthly, to ensure any changing needs were identified. The provider’s self assessment said that people living at the home or their representatives were encouraged to be involved in the development of the care plan and were asked to read and sign the document. However there were no signatures in the two files of the people that were case tracked to demonstrate that relatives had been involved in the formulation of the care plans. However in one of the files seen there was clear evidence that information had been Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 12 obtained from this person’s next of kin. Draft care plans had been written with information provided by the next of kin. These had then been further developed and typed up by the home to provide the formal care plans for this individual. As confirmed in the provider’s self assessment, records were seen to demonstrate that appropriate systems were in place for individuals to access health services and for these services to be provided within the home if required, such as G.P, dentist, optician, chiropodist, physiotherapy, continence assessment nurse and district nurse team. On the day of this inspection visit the chiropodist was at the home. Staff were observed encouraging individuals to be seen by chiropodist and appointments were held in private to ensure each person’s privacy and dignity was respected. As confirmed in the provider’s self assessment, records were seen to demonstrate that all staff who were authorised to administer medicines had undertaken medication training and held or were working towards a National Vocational Qualification (NVQ) at level 3. Medication practices were generally satisfactory. Medication records were completed accurately and indicated that medications were being given as prescribed. The supplies held corresponded with the medications listed on the records seen. There were three areas that need to be addressed. At the time of this inspection the home did not have any controlled drugs that needed to be recorded in a Controlled Drugs register by law. However as a good practice measure the controlled drugs that were used, had been recorded on loose sheets that were of the same format as a Controlled Drugs (CD) Register, but were not by definition (of the Royal Pharmaceutical Society’s guidance) a controlled drugs register. This means that, if in the future the home has any drugs that by law must be stored in a CD register, the current system in use would not be acceptable as it is not secure. A thermometer was in place to record the temperature of the clinical fridge but this did not record the minimum and maximum fridge temperatures to check the clinical fridge was running at the correct temperature. The record sheet showed that the temperatures for the clinical fridge had not been recorded for two days, therefore had the fridge not been working correctly this may not have been noticed and could have affected the medication stored in it. Records seen demonstrated that privacy and dignity was upheld for individuals, such as the records seen for one person that stated that they were unable to open own their own mail and instructed staff to pass this persons mail to their next of kin. Chiropody treatment was given in private, not in communal areas. Care plans reflected how individuals’ privacy and dignity was to be maintained. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 13 Observations of staff with people living at the home were positive and demonstrate a relaxed atmosphere with a good rapport between the staff and the people using the service. Comments received from relatives included ‘the staff are friendly and contact us if there are issues with mum’ and ‘the care seems good’. Discussions with the people living at the home were limited to a few people, as many where unable to express their views. Those that were able to express their views were very positive saying that the home was excellent and the staff were very caring and friendly. Information received within surveys was also positive, one person wrote, “The staff at the care home have always given mum plenty of fuss and attention to her every need.” Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,4 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s social and recreational needs were met. People were supported to maintain contact with family and friends. The quality and variety of meals provided was enjoyed by the people using the service. EVIDENCE: The provider’s self assessment stated that Holly Tree has a varied social programme to suit all. It said that residents and their families are encouraged to participate in the activities if they wish to do so. A weekly activities poster is displayed and other events are displayed on the notice board in reception, advertising forthcoming events for visitors. Information was seen on the board in reception of the activities planned, such as manicures, sing along, soft ball games, music and dance, dominoes, price is right, hand massages with hand creams, noughts and crosses, quizzes, chair aerobics, sherry mornings and snakes and ladders. The local Church visited on the day of this inspection visit for hymn singing. The deputy manager confirmed that one person living at the home visits their Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 15 local church and their church supported them to do this. They were also visited at the home by their priest. As confirmed in the provider’s self assessment an activities book with an accompanying photo album was held to show what activities have been undertaken. As stated earlier in this report discussions with the people living at the home were limited to a few people, as many where unable to express their views. Those that were able to express their views confirmed that activities took place at the home. One person spoken with also said that staff at the home supported them to use a voluntary support service whilst in town. This was pre booked by staff when this person wanted to go shopping and then the person was met in Derby by a volunteer who supported them to shop for a maximum of 2 hours, when they then returned to the home in a taxi. Relatives spoken with on the day of the inspection confirmed that they were aware of activities and entertainment that was undertaken at the home. Comments within surveys from relatives indicated that they felt more entertainment would benefit the people living at the home. One person felt there was not enough activities for people that were less able to participate in group activities. The lack of a designated activities coordinator has the potential to affect the planned activity schedule. Discussions with staff confirmed that as the care staff were responsible for undertaking activities any urgent care issues could affect or disrupt the activities schedule. The provider’s self assessment stated that people living at the home were able to receive visitors in private if they wished to do so. Visitors that were spoken with confirmed this and said that they were made to feel welcome. As stated in the provider’s self assessment individuals preferences in relation to social activities, cultural interests, meals and religious needs were recorded in their care plans seen. The provider’s self assessment stated that individuals are free to choose what time they get up and go to bed and where they spend their time during the day. This was confirmed by the people that were spoken with and from observations of people throughout the day of this inspection visit. The provider’s self assessment stated that they offered a varied, balanced and nutritious menu and that visitors were welcome to join their relatives for meals. Menus were seen and ran over 4 week period and weekly menus were on display on the board in entrance. The menus demonstrated that alternatives were available. It was noted that the home did not have picture menus, which would support people that were no longer able to read, in choosing their Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 16 meals. Everyone spoken with confirmed that the meals provided were very good. Diabetic diets were catered for and soft diets as required. Holly Tree Lodge Residential Care Home DS0000073088.V375560.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are addressed promptly by the service to ensure any issues are resolved quickly. The practices in place and the training provided ensured people were protected from abuse. EVIDENCE: As stated in provider’s self assessment the home operated an open door policy and a clear complaints procedure which was included in the service users guide, staff handbook and posters which were displayed within the home and included the proprietor’s telephone number and how to contact the Care Quality Commission. As stated in provider’s self assessment Holly Tree Lodge had received no formal complaints since the change in ownership of the home. Information provided by the manager said that the people living at the home, their families and the staff team voiced any concerns they had openly to the manager. We have received one complaint regarding the care of an individual living at the home. This has been returned to the provider to investigate and at the time of this visit was being investigated. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 18 Comments from people living at the home and visitors that were spoken with indicated that they would report any concerns they had to the manager and they appeared confident that any issues they had would be addressed. The provider’s self assessment said that people who were able to vote, were offered the choice of voting either at the polling station or staff at the home assisted them to apply for a postal vote. The provider’s self assessment said that new staff received in house video training within their first month of employment on issues such as different forms of abuse. Staff spoken with also confirmed that they had attended safeguarding adults training with Derbyshire County Council and staff training records seen confirmed that this training had been undertaken this year. The staff spoken with demonstrated a good understanding of the procedures to follow in the event of any safeguarding concerns The Safeguarding policy at the home was is in line with Local Authority policy, who takes the lead in safeguarding adult’s investigations. This ensures that all staff have information on the local authority guidance and procedure to follow. Holly Tree Lodge Residential Care Home DS0000073088.V375560.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Holly Tree Lodge provides a comfortable and clean home for the people living there. EVIDENCE: The provider’s self assessment said that the home offered a clean and homely environment. It stated that the maintenance person and house keeping team worked hard to keep the home clean, tidy and safe for everyone. From observation and discussion with people living at the home and their visitors this was confirmed. The home has adequate bathing, toilets facilities and a new wet room. As stated in the provider’s self assessment there is a call system in every room and a passenger lift for people to access the first floor. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 20 Wander mats were provided in bedrooms for individuals that required them and those who are unable to use the call bell system. Doors such as the laundry, kitchen, the office and the treatment room had coded locks to ensure the safety of individuals was maintained. The provider’s self assessment said that the garden and grounds were well maintained and used by the people living at the home and their visitors in the warmer weather. The garden was seen and had been well maintained with secure grounds and seating provided. However the exit from the conservatory to the garden area has a small step that is not suitable for the less mobile person or someone that uses a wheelchair. A handrail has been fitted outside the French doors that lead to the garden but this was blocked by the door when open, so making this handrail inaccessible. Staff and residents spoken with confirmed that the side door was mainly used to access the garden as it provided better access. The laundry room was seen and housed new equipment, such as a new washing machine with a built in sluicing facility, to ensure laundry was washed at the appropriate temperatures and disinfection standards were maintained. A new dryer had also been purchased. The laundry was staffed daily from 8 am to midday. Care staff completed any other laundry jobs out of these hours. Everyone spoken with confirmed that they were happy with the laundry service provided. Holly Tree Lodge Residential Care Home DS0000073088.V375560.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A competent and trained staff team meets the needs of the people living at Holly Tree Lodge. The recruitment practices do not ensure suitable people are employed. EVIDENCE: As stated in provider’s self assessment the rotas demonstrated that there was sufficient staff available day and night to ensure the needs of the people using the service are met. Staff spoken with also confirmed this. Within the staff surveys that were completed last October there was reference to improvements that were needed regarding the staff teamwork and comments that staff morale needs boosting. However from discussions at this inspection visit with several staff, it appears that issues have now been addressed and there is a positive staff team and high staff morale. The provider’s self assessment said that the majority of the staff have either completed a National Vocational Qualification (NVQ) in care at Level 3 or were currently studying towards this qualification. The NVQ records show that out of Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 22 the 13 permanent care staff there are 7 staff with NVQ2 and all are now undertaking NVQ 3 training. The deputy manager is now doing NVQ 4 in care. As stated in provider’s self assessment, enhanced Criminal Records Bureau checks and Protection of Vulnerable Adults checks had been obtained within the two staff files seen, this indicates the staff employed were safe to work with the people using the service. However the staff recruitment files seen did not have full employment histories recorded on their application forms. Both staff files seen had two references, one had a reference from their last employer but the other did not. The reason that this had not been identified easily was because a full employment history was not given, such as day and month of each job start and end date. This would have enabled the employer to clearly identify any gaps in employment that needed to be explored and identify the person’s last employer. Staff surveys confirmed that new staff shadowed another staff member through their induction period to enable them to get to know the people living at the home and to ensure new staff were supported and guided to undertake their job competently. Records of induction training were seen. Staff spoken with and the surveys received by staff also confirmed that the staff were provided with the relevant training to ensure they were competence to do their job. Records showed that the training completed this year included, fire safety, first aid, Safeguarding Adults, Infection Control, food hygiene, dementia awareness, health and safety and moving and handling that had been booked for June 09. Holly Tree Lodge Residential Care Home DS0000073088.V375560.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33,35,36,37 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A qualified and experienced manager is able to provide support to an experienced staff team; however lack of evidence of staff supervisions and health and safety practices potentially puts people at risk. EVIDENCE: The provider’s self assessment stated that the registered manager has NVQ 4 and has worked at the home for over four years. The deputy manager has enrolled on NVQ level 4 in health and social care and the assistant manager/ administrator is qualified to NVQ level 3 in health and social care and has been at the home for four years. Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 24 The provider’s self assessment stated that the managers of the home ensured the ethos of the home is open and transparent in all areas of the running of the home. As stated earlier in this report the discussions with several staff confirmed there was a positive staff team and high staff morale. Staff felt that they were well supported by the management team. The provider’s self assessment stated that quality assurance systems were in place to ensure the home is effective in meeting the needs of the people using the service. It said that satisfaction surveys are issued to relatives and staff. No satisfaction surveys had been sent out in the last six months since the home has been registered with the new provider. Records were seen to demonstrate that quality audits were undertaken monthly by the management team, with corrective actions identified and implemented. Satisfactory systems were in place for managing individuals monies, which were held by the home for safe keeping. This ensured the finances of the people living at the home were safeguarded. Minutes of a staff meeting that took place in April 2009 were seen. The deputy manager did confirm that the new provider had attended the staff meeting to introduce himself to the staff team. Staff spoken with said that they had received supervision, however only recent supervision records were in place. These records showed that two staff had received supervision in March 09. No other records were available to see. The provider’s self assessment stated that the policies at the home had last been reviewed during 2008. However it was noted that the policies seen did not have a date to demonstrate when the policy was written, a review date, or demonstrate that policies had been updated since the registration of the new provider. None of the policies seen, other than the complaints policy referred to Holly Tree Lodge Limited. Therefore it is difficult to determine if these policies were updated in line with current practice. The provider’s self assessment indicates that not all equipment and appliances at the home had been serviced as required. This was further assessed at the inspection visit. The 5 year electrical re wiring certificate was no longer valid. This had expired in March 2009. The Fire Fighting equipment had not been serviced since February 2008. Records demonstrated that the emergency lighting within the home was last tested in September 2008. The records showed that the Gas appliances within the home had not been serviced since March 2008. Records were in place to show that fire alarm tests were carried out weekly and a fire drill had been undertaken in April 09. Holly Tree Lodge Residential Care Home DS0000073088.V375560.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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 2 2 Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement The maximum and minimum temperature of the clinical refrigerator should be recorded each day to ensure medications are stored at the correct temperature. Two written references including a reference relating to the person’s last period of employment, which involved working with children or vulnerable adults must be obtained prior to employment. This is to ensure that people living at the home are protected by the homes recruitment policy and practices. Full employment histories and a satisfactory written explanation of any gaps in employment must be in place for all staff working at the home. This is to ensure that people living at the home are protected by the homes recruitment policy and practices. Effective quality assurance and quality monitoring systems must be put into place at the home. DS0000073088.V375560.R01.S.doc Timescale for action 20/07/09 2 OP29 19 Schedule 2 20/07/09 3 OP29 19 Schedule 2 20/07/09 4 OP33 24 20/11/09 Holly Tree Lodge Residential Care Home Version 5.2 Page 27 5 OP36 18(2) 6 OP37 17 These systems must be based on the views of the people that use the service and their representatives Staff must receive formal 20/11/09 supervision to ensure they are supported in their job and any development and training needs are identified. Holly Tree Lodge Limited’s 20/08/09 policies, procedures and key documents must be in place, to ensure the home is well run. To ensure the safety of people using the service, the staff and visitors to the home are protected; you must have the electrical systems within the home serviced every 5 years. This must be undertaken by a suitable trained person. URGENT ACTION LETTER SENT 22.05.09 The fire fighting equipment at the home must be checked and tested annually by a suitable trained person, to ensure the fire equipment in place is in good working order. URGENT ACTION LETTER SENT 22.05.09 The emergency lighting at the home must have a full check and test of systems every six months by a suitable trained person to ensure the emergency lighting is in good working order. URGENT ACTION LETTER SENT 22.05.09 To ensure the safety of people using the service, the staff and visitors to the home are protected you must have the gas appliances within the home serviced annually. This must be undertaken by a suitable trained DS0000073088.V375560.R01.S.doc 7 OP38 13 ( 4) 22/06/09 8 OP38 23 (4) (c) 22/06/09 9 OP38 23 (4) (c) 22/06/09 10 OP38 13 ( 4) 22/06/09 Holly Tree Lodge Residential Care Home Version 5.2 Page 28 person URGENT ACTION LETTER SENT 22.05.09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations To ensure the home is able to comply with the law, when they are in receipt of Schedule 2 Controlled Drugs they should purchase a C.D register. As additional records of receipt, administration and disposal of schedule 2 controlled drugs must be held within a ‘register’. This is explained within the Pharmaceutical Societies guidance as ‘a bound book or register with numbered pages’ An activities coordinator should be appointed to ensure planned activities are undertaken as scheduled. Picture menus should be used to support people in choosing their meals. The exit from the conservatory to the garden area should be improved to ensure it is accessible for everyone. Staff should receive regular supervision Policies should have a date to demonstrate when the policy was written and a review date. 2 3 4 5 6 OP12 OP15 OP19 OP36 OP37 Holly Tree Lodge Residential Care Home DS0000073088.V375560.R01.S.doc Version 5.2 Page 29 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.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 © (2009) Care Quality Commission (CQC). 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. 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