Inspection on 22/11/05 for The Hollies & Hollies Lodge

This inspection was carried out on 22nd November 2005.

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 14/11/06

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 22nd November 2005 09:30 The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 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.V270279.R01.S.doc Version 5.0 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.V270279.R01.S.doc Version 5.0 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 Mental disorder, excluding learning disability or registration, with number dementia (18), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 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 self caring 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 Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine announced inspection carried out between 9.30am and 4.30pm.The registered provider and the manager have a good knowledge and understanding of the regulation and inspection process and use the event as part of the ongoing review of the service. Steve Orrick the registered provider and Linda Quarendon the manager were both available throughout the inspection. Some areas of the home were seen during the discussions with four residents and three staff. Three comment cards from residents and one comment card from one of the healthcare professionals and one from a relative were received by CSCI prior to inspection. All the comments were positive and expressed satisfaction with the service and facilities. All the comments have been incorporated into the report except where there has been a personal or individual reference and these comments have been passed directly to the management for their attention. A small sample of records relating to residents staff and training were seen and discussed. Feedback was given to Steve Orrick and Linda Quarendon. What the service does well: The Hollies and Holly Lodge provides a consistently high standard of care in a homely environment to adults with an enduring mental illness .The home is well managed and maintains a stable staff group who have a clear understanding of the resident’s healthcare needs. Resident’s spoken to on the day said that they are well looked after and can rely on the staff to help them to look after themselves as much as possible. The staff and management encourage resident participation in their own care and the running of their own home wherever possible. The staff commented on the positive support and supervision and the good direction and leadership by the management. This home works consistently to ensure resident’s needs are met and their individual rights respected and upheld, and promote an inclusive and open style of management. The management and staff are committed to training and staff development and can demonstrate that they have the skills and expertise to meet the needs of people with enduring mental illness The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 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.V270279.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,4,5 Prospective residents or their representatives have the information they need to make an informed choice about where to live Residents and their relatives are invited to visit or stay at the home prior to admission. Residents have individual contracts issued on admission. EVIDENCE: The home has a stable group of residents in that some of them have lived at the home and in the care of the registered provider for 25 years or more. Each resident has a contract setting out the terms and conditions of residence which is maintained on their personal file. Prior to any admission to the home regular visits are encouraged to help with the integration process and also to provide an opportunity for the resident group to meet with any newcomer. The inspector was advised that due to the health needs of some of the residents they are not always able to deal independently with their own contract agreement and this is usually undertaken by the placing agency with the support of the mental health team or psychiatrist. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9,10 Residents are consulted and asked to make decisions about their lives with assistance as needed. Residents are supported to live an independent lifestyle and to take managed and assessed risks as part of every day life. Residents are aware that information about their health is maintained safely. EVIDENCE: Care files are maintained in a secure and safe environment and reflect the individual health care needs and personal views of the residents. Staff can access the care information easily. Each resident keeps a personal diary where they are encouraged to record anything that may impact on their care or way of life, or relationships. With the residents permission the diaries are used during discussions with their key worker or with the manager at the regular reviews. Weekly meetings offer an opportunity for the residents to have a say in the running of the home and organising their group and individual social activities and interests, especially if they have a seasonal flavour. They also discuss meals and menus, outings and any in-house activity or changes. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 10 Residents spoken to during the inspection said that they don’t always go to the meetings but feel that they have a say in what they wish to do. A comprehensive risk assessment for the premises and grounds has recently been completed which complements the personal risk assessments. The manager intends to carry out an annual appraisal with the residents over and above the regulatory care reviews already in place to monitor the risk elements of the care plan and acknowledge or recognise subtle changes and progress. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 Residents are treated with respect and are enabled and supported in family, friends, peer relationships and activities. EVIDENCE: Residents can access activities and recreational sessions in the home and include a music appreciation group, and music to movement group. Once a week a tutor from the learning enhancement ( learning skills unit) attend the home and residents can be involved in further education projects which include developing English and maths skills. Residents can undertake supported learning projects or work independently. Residents also have the opportunity to be involved in the local community and church activities. The management and staff arrange short trips everyday to the city or local county towns or villages. Residents are actively encouraged and supported by staff to pursue and maintain their personal interests. Residents spoken to said that in the run up to Christmas they will be visiting garden centres; the cinema to see one of the latest releases and shopping. One of the staff is to put on a disco, and there will also be a Christmas card competition alongside the plans for a traditional Christmas at the home. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 12 Holly Lodge is a separate part of the home with its own kitchen and laundry, and communal rooms. The services and facilities area have not been used for some time and the plan is to convert this area into an activities club room. The room will be equipped with the snooker table and other equipment including computers. In addition there will be a microwave and facilities for making drinks. It is hoped that the conversion will be completed over the next three to six months. Residents said that their friends and family can visit at any time and that they also have established close friendships within the resident group. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20,21 Residents are well supported by staff as required, and in their own preferred style. Residents do not control their own medication. There are well managed procedures in place for the administration of all prescribed and homily medication. There is evidence of good practice in place for dealing with older people within the resident group, with evidence that staff have a knowledge and understanding about dealing with death and bereavement. EVIDENCE: Residents confirmed that the staff are helpful and spend time with them on a one to one basis. None of the current resident group can safely manage their own medication and the home have a robust system in place for administering medication. Residents are accompanied or escorted to visits to the hospital as well as meeting and reviews with the psychiatrist or community nurses. The staff group seen on the day staff gave good accounts of care input and where they are encouraging individual lifestyles and self expression. They spoke confidently and competently about their roles, responsibility to the residents and confirmed that the staff group consistently meet the needs of the residents and are well supported by the management. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not inspected on this occasion EVIDENCE: This standard not inspected on this occasion The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Residents live in a homely and comfortable environment. The home is clean and hygienic. EVIDENCE: Residents have a choice of communal space, including a non-smoking sitting room conservatory and dining room. The rooms are comfortable and well maintained. Resident’s rooms are furnished and designed as they choose, and are maintained by them with assistance from their support workers, and with managing their laundry and other domestic tasks. By invitation a small number of residents rooms were seen on the day and reflected individuality and personal choice. The management acknowledge that some areas of the older building and general décor are looking tired and need to be reviewed and refurbished. As previously stated the registered provider has a draft proposal for the development of the site to include new buildings and self contained accommodation and in one of the later phases to upgrade and refurbish the original building to a good standard and in compliance with the National Minimum Standards for Younger Adults. The majority of residents are heavy smokers and have a separate sitting room where they can smoke. This room gets very heavy use as do the carpets and furnishings which are constantly being repaired or replaced. The management The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 16 are reviewing the way in which the room is used and also seek ways in which it can be refurbished and more easily maintained. As previously stated under standard 19-21 one area of the home is being converted to provide better games and activity room and facilities for making snack meals and drinks. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34,35 Residents are supported by a confident and competent staff team. Residents benefit from a well supervised and managed staff team. Staff can demonstrate that they are clear about their individual roles and responsibilities . The homes recruitment and selection process procedures ensure that residents are protected. EVIDENCE: There are sufficient numbers of staff to support and meet the health care needs of the residents. Members of staff are available each day to escort or accompany people who wish to go out. The manager is highly committed to training and promotes and supports staff to complete mandatory and specialist training both externally and in-house. During the discussions the staff confirmed that training opportunities are available to them and two staff have completed NVQ 2 this year and a further two will be considering the course next year. Specialist training sessions have been accessed at Hellesdon hospital and have included talks on resident fitness, Bi-polar conditions; nutrition, and dietetic advice. Ten staff have received basic food hygiene training, fire prevention training and first aid Staff supervision is given a high priority and the manager has recently reviewed the process to ensure that the formal sessions are booked and prepared for well in advance. Informal supervision takes place on a daily basis, when the handover sessions take place. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 The home is well managed with clear leadership and direction, both by the registered provider and the manager who give the highest priority to the wishes and needs of the residents. EVIDENCE: This home is well run and well managed. Linda Quarendon the manager and Steve Orrick the registered providers regularly work alongside the staff and support residents. From the discussions with staff and residents and the comments from other health care professionals there is a very democratic and open style of management and allows residents to express their views and opinions. Care records and staff files including supervision records are in place and evidence reflective and direct practice and good administration .One resident said that they have lived at the home for a long time and rely on the manager and the provider for everything and they feel safe and would not want to live anywhere else. The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x 3 3 Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Hollies/Hollies Lodge Score x 4 3 3 Standard No 37 38 39 40 41 42 43 Score 4 4 x x x x x DS0000045189.V270279.R01.S.doc Version 5.0 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hollies/Hollies Lodge DS0000045189.V270279.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 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. 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