Inspection on 14/11/06 for The Hollies & Hollies Lodge

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

The Hollies & Hollies Lodge 04/11/08

The Hollies & Hollies Lodge 22/11/05

The Hollies & Hollies Lodge 14/06/05

The Hollies & Hollies Lodge 07/12/04

The Hollies & Hollies Lodge 30/06/04

The Hollies & Hollies Lodge 22/01/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 The Hollies/Hollies Lodge Brick Kiln Lane Morningthorpe Norwich Norfolk NR15 2LH Lead Inspector Mrs Susan Golphin Unannounced Inspection 14th November 2006 10:00 The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies/Hollies Lodge Address Brick Kiln Lane Morningthorpe Norwich Norfolk NR15 2LH 01508 530540 01508 530540 info@holliesrch.co.uk 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) Calrhyros Ltd Mrs Linda Ann Quarendon Care Home 23 Category(ies) of Learning disability over 65 years of age (3), registration, with number Mental disorder, excluding learning disability or of places dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (20) The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: The Hollies and Holly Lodge is situated in a rural area close to the village of Long Stratton in South Norfolk, and provides residential accommodation in single rooms, for people with mental health needs. Holly Lodge offers selfcontained accommodation to service users who wish to remain within the general support services of the home but who are able to maintain a more selfcaring and independent lifestyle. The service provision available includes personal care and support by care staff to promote and maintain their individual lifestyle. There are a range of activities and social events that take place on a daily basis including therapy sessions, outings or shopping trips for which transport is readily available. The fees per week range from £307-£395. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers the service to people. The key inspection has been carried out by using information from previous inspections, information from the providers and the residents as well as others who work in or visit the home. This report gives a brief overview of the service and the current judgments for each outcome group. What the service does well: What has improved since the last inspection? The staff group continue to achieve NVQ accreditation, and five staff now hold NVQ2 qualification. Specialist training for managing challenging behaviour and non-abusive approaches to physical intervention have been taking place this year. General low maintenance of the premises is continuing which has included the redecoration of resident’s rooms and replacement of carpets and a review of some of the plumbing in each room. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 6 In the last year there has been a lengthy review carried out by the commissioners of the service. The review looked at the current fee levels and also at each resident’s individual mental health and care needs. The designated smoking room is in use constantly and there is heavy wear and tear especially on carpets and furnishings. This year the floor has been laminated with a hard floor surface, which can withstand heavy use and can be maintained more easily. Other minor works have also been carried out in the last year At the previous inspection plans were being prepared by the registered provider to develop the surrounding land with a new stand -alone unit and in addition a small ‘housing with care’ project. The original home will then undergo a major refurbishment. The planning application has been submitted twice and refused. Changes to the plans have been implemented and will be submitted for the third time. It is acknowledged that the major refurbishment cannot take place until approval for the planning proposal is agreed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 2 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home promotes the involvement of residents in achieving their own goals and aims. EVIDENCE: The majority of residents have lived at the Hollies for many years and their aspirations and needs are well known, and mostly unchanged. The management carry out regular reviews and re assess individual needs and wishes as part of the overall care plan. There is also a weekly meeting where the residents can share ideas. Each resident has their own care diary, which is used to express their thoughts and feelings through the written word or pictures and share them with their key worker. This non- threatening tool is used to encourage the residents to participate in their own care planning processes and to retain some responsibility for their day-to-day lives. Residents confirmed that it is sometimes useful to be able to write down their feelings especially when their illness is overwhelming them. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 9 Staff interviewed on the day were able to demonstrate that they are clear about their objectives in meeting resident’s needs and supporting them. Information about the complaints procedure which is included in the service user guide needs should be reviewed and updated (see recommendation) The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,9 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The quality outcome for this group of standards is good. The service provides residents with the opportunity to achieve their own aims and goals within the personal plan of care. EVIDENCE: Six survey comment cards were received prior to the inspection and the overall outcome is that the residents are satisfied with the service they receive and can rely on the managers and their key workers to help them to achieve their personal aspirations within the limitations of their illness. Weekly meeting with staff and with each other provide a forum for sharing concerns or worries and also for planning activities and discussing in- house events. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 11 Some residents said that they cannot always cope with the planned group activities or meetings, but were quite clear about being able to have a say in their own day to day care. Care plans for each resident are in place and accessible to staff. Each resident has a personal care diary where they are encouraged to record anything that might affect their lifestyle; they can then discuss the diary entries if they wish during reviews with their key workers or the manager. Risk assessments are carried out on the premises and individually as part of the overall plan of care. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16,17 Quality in this outcome area is (good) The service provides ample opportunity for residents to live their lives as they wish and recognise their right to make choices and decisions on a daily basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are offered a wide range of activities / outings each day and include trips to local villages, shops and pub. There is a music appreciation group and a recently started creative writing group, and sessions take place each week. In addition there are art and crafts activities usually with a seasonal theme and once a week there is an ‘extend’ exercise session. Residents can also visit the cinema and community and church activities as they wish. Three residents spoken to during the inspection confirmed that they could always take part in some chosen activity each day. Others said that they were looking forward to the Christmas season, as there is always ‘nice things to do’. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 13 One area of the home is currently being converted into a clubroom / activities area with separate sitting room and kitchenette. Residents will be able to use the area for any indoor games or social activity. They will also have access to IT equipment. The registered provider is looking at a range of different floor covering to find a suitable and hard -wearing material and it is hoped that the work will be completed over the next few months. Residents are encouraged to maintain friendships and relationships with family and people outside of the home as well as their fellow residents. Residents said that they like the choice of meals and contribute to the debate about meals and meal planning. There is a set daily menu which is displayed each day with plenty of options available and residents confirmed that they have a good choice of meals and snacks available to them, and are always consulted about changes in the menu or any special celebratory meal planning. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19,20 Quality in this outcome area is (excellent) The service promotes and encourages good relationships between staff and residents and demonstrates a sound knowledge and understanding of people with mental health needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents seen on the day confirmed that they are well supported by staff and feel safe and secure in the home. Examples of individual support and issues relating to self -care and decision- making were discussed. The manager acknowledged that residents are encouraged to attend to their own needs and personal intimate care but often need clear direction and supervision to maintain the agreed plan of care. None of the current resident group can safely manage their own medication. The managers use a robust system for the administration of medication. Two people are required to check cross check and record each medication issue. All the staff has completed training in the management and administration of medicines. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 15 Within the last seven days all the residents have received a medical check up through their GP service. Routine tests are carried out to monitor general physical well being and to screen for any illness or possible underlying infection. Regular reviews of medication are also carried out as are planned appointments to see psychiatrists and consultants as part of the ongoing monitoring of each residents well being. The staff spoke confidently and competently about the support they provide and about their day to day responsibilities as key workers. Residents were also complimentary about individual members of staff and the manager and gave examples of help and support, which demonstrates that the service promotes trusting and inclusive relationships. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22,23 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home maintains a clear and effective complaints process. The staff are made aware of the process as part of the induction training, which looks at the values, and principles of care. In the information booklet for prospective clients and commissioners the information relating to complaints and compliments needs to be more detailed so that it is clear about how to complain or raise issues with the management (see recommendation) Residents confirmed during discussions and in the comment cards returned to the CSCI that they can discuss any concerns they might have quite openly with the management or their key worker. Staff regularly attend training on the protection of vulnerable adults and specialist training in conflict management, and managing aggression and non-abusive intervention. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,30 Quality in this outcome area is (adequate) Work on the plan to upgrade and refurbish the premises should be continued This judgement has been made using available evidence including a visit to this service. EVIDENCE: Only some elements of this standard have been inspected on this occasion. As reported previously the registered providers have a major re development proposal in place to upgrade the present premises and to develop the site with a purpose built unit and self contained accommodation. Unfortunately the planning application has been refused on two occasions and is having to be re submitted by the registered provider for a third time. It is acknowledged that this situation is delaying the refurbishment of the original premises. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 18 The residents in the home have a range of complex needs and many of them preclude the individual from being able to manage and maintain their own care and environment independently. Some resident’s rooms would benefit from a general upgrade and redecoration but the residents themselves are reluctant to agree to the activity, or feel unable to deal with the upheaval the activity might create. Carpets and other furnishings are constantly being cleaned or replaced. In the last six months the smokers room has been redecorated and the carpet replaced by a wood-floor laminate. Three of the older style televisions. have been replaced with wide screen digital televisions for each of the communal sitting areas. All the communal areas are well used and as agreed at the previous inspection much of the building is in need of major refurbishment. Some minor works have been carried out this year and apart from general redecoration of some bedrooms and smokers sitting room one of the downstairs showers has been re tiled and an adjustable aid installed for one of the WCs. The traps and ubend pipe work around the wash hand basins in resident’s rooms have also been cleared, cleaned and replaced where needed. One of the areas in the home is being converted to a games room with facilities for making snacks and drinks. At the time of the inspection a suitable and durable floor surface is being sought. (See recommendation) The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34,35 Quality in this outcome area is (good) The recruitment and selection procedures ensure that residents are protected. Residents benefit from a well supervised and managed staff This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were seen on the day of the inspection. Staff confirmed that they receive regular supervision and contribute to the sessions. Each member of staff has a training file, which is their responsibility to maintain. A copy of the duty rota is displayed and the rota indicates in advance when the supervision sessions will take place. Informal supervision takes place at each of the hand over sessions on a daily basis. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 20 There are sufficient numbers of staff to meet the resident’s needs including personal and social time and escorting or supporting people when they are outside the home. The registered provider and manager are committed to formal training and provide staff with the opportunity to complete both mandatory and specialist training as well as obtaining NVQ qualification. A further two staff have completed their NVQ 2 this year, bringing the total to five. (41.67 of the staff total.) The three staff seen on the day confirmed that they are well supported by the management and spoke confidently and competently about their roles and responsibilities within the home. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39,42 Quality in this outcome area is (excellent) The home is well managed with clear leadership and direction. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This establishment continues to be well managed and maintained. Both the registered provider and manager work directly with residents and staff. (Which include on -call and sleeping in duties) From the discussions with residents, staff and comments from other health care professionals as well as observations made on the day; the democratic style of management is being maintained and allows residents and staff to express their views and opinions openly. A small sample of staff files and financial details relating to two of the residents were seen and demonstrate good administration is in place and up to date. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 22 Annual quality surveys are issued to residents, or their representatives, relatives, social workers and other health care professionals The results are collated and made available to all those who may have participated in the survey. The most recent survey provided an overall outcome of 94 satisfaction with the service. Twelve of the twenty three residents have lived at the home for between ten and twenty years and confirmed that the home provides the safety and stability they need to give them a sense of security and a lifestyle they can determine for themselves within their own limitations. The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 3 X The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations It is recommended that the complaints procedure be reviewed and updated to include a clear process for residents and relatives to follow in the event of a complaint. It is recommended that the registered provider continue to seek planning approval for the proposal to develop the site of the home to include stand alone unit and supported living accommodation in line with the National Minimum Standards for Young Adults. Once completed will allow for the main building to undergo refurbishment and upgrade. 2 YA24 The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 The Hollies/Hollies Lodge DS0000045189.V320566.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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