Care Home: Holly Lodge

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What the care home does well The registered manager had responded to the previous inspection report with comprehensive improvements. All requirements and the majority of good practice recommendations required at the last inspection visit had been actioned. There was up to date, easy to understand information about the home, with alternative versions for people who may not be able to read or understand written information. Everyone living at the home had been given a comprehensive contracts and terms and conditions, which were clear and easy to understand. Comments were positive and included, "knew it was a well run home." Review records contained the view, "the choice of home had been right, and staff were both positive and caring" and "competent was being cared for in a safe and comfortable environment." The manager and staff make sure that each person, and as appropriate, their relatives are involved in the plan of how their care is to be provided. The sample of people`s care plans looked at, were up to date. Medication storage was secure, and medicine records were clear and generally accurate. This meant that each person`s medicine requirements were well managed in a safe environment. All of the improvements required at the last inspection visit relating to medication were now in place. The home had very good relationships with the local GP`s and other health care services, such as the community dietician and other specialist therapists, providing support for people living at Holly Lodge. We saw that staff noted that a person had become unwell and lost weight, and the advice of the GP and dietician was sought and acted upon. This demonstrated the excellent level of trust and professional respect between the home and primary care services. The people living at the home were encouraged to treat Holly Lodge as their own home and to be as independent as possible. People were encouraged to choose the decor of their own bedroom and personalise it with their possessions, furniture and bedding if they wished. We saw lots of examples of people being able to make choices about their daily routines, activities and meals. They were encouraged and supported to take an active part in meetings and surveys at the home. The residents meetings were well established and generally well attended, with notes of topics discussed and action taken as a result. Relatives were also welcome to attend meetings and it was positive that the registered manager had an `open door` policy to encourage relatives and people living at the home to talk to her on an individual basis. We noted that there was good involvement in the running of the home and people had contributed their views about the activities and outings planned for the spring and summer months. The home had good links local churches and small groups of people enjoyed the activities provided by people who visited regularly to organise events such as activity classes, exercises and bingo. There was also a monthly church service at the home. Arrangements were in place for ministers from other faiths to visit individual residents at the home, at their request. For example the one person regularly attended Methodist services. The menus offered a range of options for each meal, which were well prepared and appeared appetising and well presented. We saw members of staff ask each person what they preferred at each mealtime, with each person`s preferences recorded each day. The meals were a high standard and the majority of food was prepared using fresh ingredients. The home was inspected by Dudley Environment Services and achieved 4 Stars for food safety and healthy eating. The staff monitored mealtimes and made sure each person was supported to eat with a sensitive approach. The kitchen was very well organised and there was a good budget for food. The cook took time and effort to obtain and prepare additional foods to meet individual food preferences. Comments from people during the visit were very positive and included, "meals are lovely" and "the food is good and plenty of it." The home had a relaxed, homely ambience and it was warm, very clean and comfortable. We received comments such as, "the home always smells nice, the cleaners do it every day", and "This is my home." Holly Lodge had a stable staff group, with many people who had worked at the home for a long time and knew the people living there very well. The staff were caring, committed and flexible, often willing to work extra shifts for the benefit of people living at the home. The following comments have been made, "very helpful", "everyone is caring." There was a warm and friendly rapport between staff and people living at the home. Staff were aware of individual peoples likes and dislikes and how to meet their needs. A response from the home`s professional healthcare survey, commented, "I have no concerns about any of the residents I see, they all seem happy and well looked after, and all staff very helpful." Good standards of health and safety continued to be maintained and the registered manager conducted regular quality audits and analysis of all accidents occurring in the home, any areas for improvement were identified and rectified. This inspection was conducted with full co-operation of the registered manager staff team and people living at the home. The atmosphere throughout the inspection was relaxed and friendly. What has improved since the last inspection? The management team had introduced improved care planning and care records. These provided improved care planning information and clear guidance so that all staff knew about each person`s needs, preferences and wishes. The records we looked at were very well completed and kept up to date. As identified as part of "what the home does well" improvements had been put in place to make the home`s medication system, as safe as possible, so that each person received their medicines as prescribed at the right time. The programme of redecoration and refurbishment had continued in a number of areas, notably the bedrooms, corridors, communal areas, bathing and toilet facilities. All issues such as new floor coverings and the compromised double glazed window units in the conservatory identified at the previous inspection have been replaced. Following the complete rewiring new attractive chandeliers and wall lights have been provided throughout the home. The garden has been improved with a paved area, new garden furniture, planters and a bird table. People enjoying the warm spring sunshine told us that they approved of all the improvements, which made their home a lovely place. The registered manager had used the training matrix and training plan to make sure all staff were up to date with mandatory and good practice training, which meant were knowledgeable and skilled to meet the needs of people living at the home. What the care home could do better: There were a few areas requiring improvement at this inspection. The registered manager must continue to monitor the way peoples medication is administered at the home, taking action to assess the competency of staff to make sure mistakes in recording are avoided and do not pose risks to peoples health and well being. There are also care records, which should be expanded to provide enhanced information for staff so that each person`s needs are fully met. The work to clarify special instructions and life story plans and personal preference plans need to be fully completed for each person. The registered manager`s plans to introduce a key worker system should be implemented to enhance the care and support provided in a more person centred way. There a small number of areas of health and safety, which need improvement, such as the management of risks associated with bedrails, and the laundry area. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Holly Lodge 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 0 2 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 37 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Holly Lodge 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA 01384373306 01384378160 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Mohammed Iftikhar Ali care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 21 The registered person may provide the following category 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 (DE) 2 Mental disorder, excluding learning disability or dementia (MD) 2 Old age, not falling within any other category (OP) 21 Date of last inspection 2 2 0 Over 65 0 0 21 Care Homes for Older People Page 4 of 37 Brief description of the care home Holly Lodge is a residential home registered to provide 24 hour care for 21 people over the age of 65. It is located on a residential road just off the main Hagley Road in Oldswinford near to the church. It is accessible by public transport and close to local shops and public houses. The home has 19 single rooms and 1 double room, 2 lounges and a conservatory. There is a well maintained garden to the front and rear and parking facilities at the side. Accommodation is provided over 3 floors accessible via passenger lifts or staircase. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last Key Inspection was on 3 and 5/04/06 and the CSCI undertook an Annual Service Review 17/04/08. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. The inspector visited the home between 08:15 and 19:30 hours. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included, discussions with the registered manager, deputy manager, and staff on duty during the visit. We also talked to people living at the home, and made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the previous Commission for Social Care Inspection. A number of records and documents were Care Homes for Older People Page 6 of 37 examined. The registered persons submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to the inspection visit. We toured the premises, looking at communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. The home had not published the range of fees for the service and people are advised to contact the home for up to date information about the fees charged. What the care home does well: The registered manager had responded to the previous inspection report with comprehensive improvements. All requirements and the majority of good practice recommendations required at the last inspection visit had been actioned. There was up to date, easy to understand information about the home, with alternative versions for people who may not be able to read or understand written information. Everyone living at the home had been given a comprehensive contracts and terms and conditions, which were clear and easy to understand. Comments were positive and included, knew it was a well run home. Review records contained the view, the choice of home had been right, and staff were both positive and caring and competent was being cared for in a safe and comfortable environment. The manager and staff make sure that each person, and as appropriate, their relatives are involved in the plan of how their care is to be provided. The sample of peoples care plans looked at, were up to date. Medication storage was secure, and medicine records were clear and generally accurate. This meant that each persons medicine requirements were well managed in a safe environment. All of the improvements required at the last inspection visit relating to medication were now in place. The home had very good relationships with the local GPs and other health care services, such as the community dietician and other specialist therapists, providing support for people living at Holly Lodge. We saw that staff noted that a person had become unwell and lost weight, and the advice of the GP and dietician was sought and acted upon. This demonstrated the excellent level of trust and professional respect between the home and primary care services. The people living at the home were encouraged to treat Holly Lodge as their own home and to be as independent as possible. People were encouraged to choose the decor of their own bedroom and personalise it with their possessions, furniture and bedding if they wished. We saw lots of examples of people being able to make choices about their daily routines, activities and meals. They were encouraged and supported to take an active part in meetings and surveys at the home. The residents meetings were well established and generally well attended, with notes of topics discussed and action taken as a result. Relatives were also welcome to attend meetings and it was positive that the registered manager had an open door policy to encourage relatives and people living at the home to talk to her on an individual basis. We noted that there was good involvement in the running of the home and people had contributed their views about the activities and outings planned for the spring and summer months. The home had good links local churches and small groups of people enjoyed the activities provided by people who visited regularly to organise events such as activity classes, exercises and bingo. There was also a monthly church service at the home. Arrangements were in place for ministers from other faiths to visit individual residents at the home, at their request. For example the one person regularly attended Care Homes for Older People Page 8 of 37 Methodist services. The menus offered a range of options for each meal, which were well prepared and appeared appetising and well presented. We saw members of staff ask each person what they preferred at each mealtime, with each persons preferences recorded each day. The meals were a high standard and the majority of food was prepared using fresh ingredients. The home was inspected by Dudley Environment Services and achieved 4 Stars for food safety and healthy eating. The staff monitored mealtimes and made sure each person was supported to eat with a sensitive approach. The kitchen was very well organised and there was a good budget for food. The cook took time and effort to obtain and prepare additional foods to meet individual food preferences. Comments from people during the visit were very positive and included, meals are lovely and the food is good and plenty of it. The home had a relaxed, homely ambience and it was warm, very clean and comfortable. We received comments such as, the home always smells nice, the cleaners do it every day, and This is my home. Holly Lodge had a stable staff group, with many people who had worked at the home for a long time and knew the people living there very well. The staff were caring, committed and flexible, often willing to work extra shifts for the benefit of people living at the home. The following comments have been made, very helpful, everyone is caring. There was a warm and friendly rapport between staff and people living at the home. Staff were aware of individual peoples likes and dislikes and how to meet their needs. A response from the homes professional healthcare survey, commented, I have no concerns about any of the residents I see, they all seem happy and well looked after, and all staff very helpful. Good standards of health and safety continued to be maintained and the registered manager conducted regular quality audits and analysis of all accidents occurring in the home, any areas for improvement were identified and rectified. This inspection was conducted with full co-operation of the registered manager staff team and people living at the home. The atmosphere throughout the inspection was relaxed and friendly. What has improved since the last inspection? The management team had introduced improved care planning and care records. These provided improved care planning information and clear guidance so that all staff knew about each persons needs, preferences and wishes. The records we looked at were very well completed and kept up to date. As identified as part of what the home does well improvements had been put in place to make the homes medication system, as safe as possible, so that each person received their medicines as prescribed at the right time. The programme of redecoration and refurbishment had continued in a number of areas, notably the bedrooms, corridors, communal areas, bathing and toilet facilities. All issues such as new floor coverings and the compromised double glazed window Care Homes for Older People Page 9 of 37 units in the conservatory identified at the previous inspection have been replaced. Following the complete rewiring new attractive chandeliers and wall lights have been provided throughout the home. The garden has been improved with a paved area, new garden furniture, planters and a bird table. People enjoying the warm spring sunshine told us that they approved of all the improvements, which made their home a lovely place. The registered manager had used the training matrix and training plan to make sure all staff were up to date with mandatory and good practice training, which meant were knowledgeable and skilled to meet the needs of people living at the home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a comprehensive and easy to read of purpose and service user guide and people living at the home have contracts terms and conditions of occupancy. This has the effect that people and their advocates have good information regarding their rights and entitlements, and how care will be provided. The home uses comprehensive assessment tools, which means that each persons needs are thoroughly assessed to ensure that their needs and preferences will be met. The home actively encourages introductory visits and there is evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. This home does not provide intermediate care, therefore Standard 6 is not applicable. Evidence: The information contained in the homes AQAA about what it did well stated, our Care Homes for Older People Page 12 of 37 Evidence: information is written in clear plain English which shows the homes objectives and philosophies, in order for the potential service users to make an informed choice. The service user has a contract in terms and conditions, which shows clear information regarding rights and entitlements and any agreed restrictions and how care will be provided. A full needs assessment is undertaken prior to admission to ensure any assessed needs can be met. Relatives are fully involved in the assessment. All potential service users are encouraged to make introductory 12 visits to the home to allow them to assess the quality, facilities and suitability of the home. The homes AQQA cited the following supporting evidence to demonstrate what it did well, our statement of purpose sets out our aims and objectives and range of facilities and services available. Service users have a detailed plan of care for daily living and longer term outcomes, which include a risk assessment. Service users case files show records of assessments undertaken including who carried out the assessment and dates of introductory visits. Results of surveys and questionnaires. We looked at copy of the homes statement of purpose and service user guide, which had been updated in March 2008 and could also be provided in alternative formats on request. We saw that the revised and updated versions for the current year were underway. The documents clearly set out the aims and objectives, admission criteria and provided good clear information about the home. Information about the range of fees and third party top up arrangements had not included in the service user guide. We discussed this omission with the registered manager who told us that the information would be added to the documents currently being revised and updated. We recommended that comprehensive information about fees should be included in the service user guide to give people full information about the service to help them make decisions about the choice of home. We looked at a sample of case files of people recently admitted to the home, which provided evidence that each person was provided with a contract and statement of terms and conditions. This document had also been revised and updated and was easy to read and understand and set out in detail what was included in the fee, the role and responsibility of the provider, and the rights and obligations of the person living at the home. Some people who had been at the home for a long time had older versions of the contract of residence, which the registered manager told us were being reissued. From the information provided at the home we noted that the majority of people were funding the costs of their own care, whilst other people were funded through the Local Authorities. There was evidence from examination of a sample of care records at the home and Care Homes for Older People Page 13 of 37 Evidence: from discussions, which confirmed the good practices claimed in the homes AQAA. Such as pre admission assessments, which were conducted professionally and sensitively and had usually involved the family or representative of the person. The pre-admission assessment documentation was well completed and individual preferences were recorded such as rising, retiring, preferred activities, likes and dislikes. This meant that staff had good and accurate information about each persons needs and preferences about how they wished their care to be provided. An example was that a person admitted for a short respite stay who wanted to continue to manage their own medication was supported to do so. Care Homes for Older People Page 14 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is comprehensive care planning, risk management and monitoring, which provides staff with the information and guidance to meet peoples needs and preferences well. Excellent multi disciplinary working takes place on a regular basis, giving people assurances that their health needs care needs are identified and well met. The service has a comprehensive medicine policy that reflects good practice and staff can identify through records exactly what has been given to people living at the home. This means that each persons medicines are stored safely and that records show that the right medicine has been given to the right person at the right time. People living at this home can be assured that they will receive dignity and respect at all times. Evidence: We looked at a sample of care records for new people admitted to the home and people who had lived at the home for longer periods of time. We saw that each person Care Homes for Older People Page 15 of 37 Evidence: had a comprehensive care plan, using improved formats. There was evidence demonstrating the good practice of involving the person and their relatives or representatives in the development and review of their planned care. We noted that the care plans were based on very comprehensive assessment information and included all essential basic information and identification of any associated risks. The addition of personal preference information and the plan to introduce life histories to record each persons preferred daily routines for staff guidance making sure that care was delivered with a person centred approach was an excellent initiative, which is being implemented well. There was evidence from records and discussions that each persons health was carefully monitored with appropriate action taken. We saw evidence of well documented health care assessments, screening, treatment and intervention. An example was where there were significant changes in one persons condition, with weight loss, some loss of mobility and general deterioration. This reflected in a review of the Waterlow tissue viability score, nutritional assessment and a referral to the GP and community dietician for advice and support and appropriate weight monitoring and increased calorific dietary intake. We recommended that an improvement should be made to the moving and handling risk assessments to incorporate all transfers and the name of the person undertaking the assessment. We noted that where people had communication difficulties care plans had been put in place, which demonstrated good practice. One persons communication plan, stated, Communication difficulties. ensure that you use good communication, keep choices simple or visual. We recommended that this could be improved with more explicit guidance for care staff about how to communicate with this person. We recommended for example that staff should use closed questions, using simple words, with face to face communication, speaking clearly at a pace the person understands. We saw that all persons living at the home had good access to health care services to meet their assessed needs both within the home and in the local community. Some people were able to choose their own GP within the limits of geographical borders and there was documentary evidence to demonstrate that all persons had good access to dentists, opticians, and other community services, such as physiotherapy services. The home does not currently have a key worker system, though the registered manager discussed ideas for the implementation of the system. We commended this as an excellent initiative and recommended that a key worker system should be introduced to enhance the quality of individual person centred care for people living at Care Homes for Older People Page 16 of 37 Evidence: home. We looked at the homes system to manage the medication for people accommodated. We noted that the supplying pharmacy, Lloyds, supported the home and provided advice related to medication issues at regular audit visits. We noted that all medication was appropriately stored in accordance with manufacturers guidance. There was a lockable medication refrigerator, which was checked daily, with the minimum and maximum temperatures documented and recorded. The correct temperature range of between 2 C and 8 C was being maintained. This meant that peoples medication requiring refrigeration was stored at the correct temperature to maintain its integrity and effectiveness. All medicines were stored securely. This ensured that each persons medication was kept in a safe environment. We looked at a sample of MAR (Medication Administration Records) sheets, which document each persons current medicine requirements and regime. These were well maintained, which meant that there was an accurate record to show medicine prescribed by their doctor was recorded, checked, monitored and administered in accordance with instructions. There were good procedures and checks in place to make sure that generally persons received their correct medicine at the right time. However we noted that one persons Levothyroxine had been increased on their MAR sheet and this needed to be updated in their care plan. We recommended that any changes to medication regimes should be reflected in the persons updated care plan. The receipt, administration and disposal of medicine were recorded. The date of opening of medicine in original containers was not documented, which meant it was less easy to carry out audits. We carried out audits on a random sample of medication to ensure that medicine had been given to each person as prescribed by the GP. Of the random audits undertaken for four peoples prescribed medication were found to be accurate, two had minor discrepancies. It was positive that the deputy manager had undertaken regular audits of the medication system and had already identified some discrepancies and possible reasons. We recommended that this good practice should be enhanced, identifying what remedial action had been put in place to prevent medication errors. This would give assurances that each person received all their medication as prescribed by their doctor at all times. From our observations and in discussions it was evident that all staff were aware of how to treat each person with respect and to consider their dignity when delivering Care Homes for Older People Page 17 of 37 Evidence: personal care. Care Homes for Older People Page 18 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is ample evidence of planned and spontaneous activities available on a regular basis offering people opportunities to take part in socially stimulating activities. People are enabled and encouraged to maintain good contact with family and friends. The dietary needs of each person are well catered for with a balanced and varied selection of foods that meets their preferences and nutritional needs. Evidence: The homes AQAA cited the following evidence of what was done well, regular planned activities which include musical afternoons, twice weekly therapy, armchair exercises, trips to the theatre, good contact with local churches to meet a spiritual needs. Small groups to local pub, garden centre, tearooms, and shopping. Good contact with family and friends. Service users preferences for social activities. Flexibility of meal arrangements. Privacy and confidentiality are observed. Service users rooms reflect their personality. Dietary needs of service users are met. Encouragement of independence and individuality. The homes evidence cited included, records of activities and interests in the home. Results of surveys and questionnaires. Minutes of residents meetings. Assessment of needs. Service users involvement. Staff meetings and care plans showing preferred modes of address. Care Homes for Older People Page 19 of 37 Evidence: Records of service users preferences. A display board in reception area of forthcoming events. Visitors policy and visitors book. Achievement of four star food hygiene award. Food and fluid intake charts. Menu board. Good communication, friendly and approachable staff. Monthly communion. We were able to verify as accurate the claims made in the homes AQAA. There was evidence during the inspection, which indicated that staff listened to people living at the home and made considerable efforts to provide flexible daily living routines, which enabled people to enjoy a good quality of life according to their personal preferences. We noted earlier in the report that the registered manager planned to introduce a key worker system, which when operated well would enable closer relationships between people accommodated and staff, where likes, dislikes and needs were known in more detail and would be met in a person centred style. Two senior staff at the home took responsibility for collating the information gained from residents and staff meetings and used their knowledge of peoples preferences to plan activities, which each person enjoyed. The activities co ordinated by two excellent members of the staff team provided wide range of activities and access to community. We were told that ideas from residents and staff meetings were visit to Safari Park, botanical gardens, theatre shows at Stourbridge town Hall, garden centres, Mary Stevens Park, and there were well advanced plans for a 100th birthday later in the year. We noted that the activities that had taken place during March included the celebration of St Patricks Day and Mothers Day as well as the birthdays of people living at home, which had occurred in March. We saw information displayed bringing peoples attention to community events and activities. It was very positive that it was understood and respected that some people preferred to spend their time in their own bedrooms, and they were supported with individual interests. We saw evidence that the staff knew and understood that one persons Methodist faith was an important part of their life and supported their wish to attend services as and when they wished. We also noted that each person had a background history completed on their files and one person had a very comprehensive my life story book, completed by their family with lots of pictures of the interesting places that this person had lived whilst working overseas. We noted that there were two people who were being cared for in bed in their rooms. We saw that real efforts were made to maintain personal contact and socialisation according to their abilities and needs. We observed lots of staff popping in to a person near to where we sat to look at the homes records. We also noted that a person who had been care for in bed for a long time had their TV, radio and CD Care Homes for Older People Page 20 of 37 Evidence: player, and lots of personal possessions in their bedroom. We looked at a sample of peoples individual activities records, which were well completed, with refusals recorded and activities offered evaluated. We saw evidence that family and friends were welcomed and people we spoke to told us they knew they could visit the home at any time. We were told that the management team always made time to talk to visitors and share information with the consent of the person concerned. During the tour of the home there was good evidence that people were encouraged to bring in their personal possessions to personalise their room. We saw inventories of personal possessions on the sample of files examined, which were signed and dated by the person or their representative and witnessed by the member of staff. We discussed nutrition with care staff and catering staff, who were knowledgeable about each persons nutritional needs. We were told that a choice was always offered, there were also diabetic and soft diets. There was also added calorific value at mealtimes for people with poor appetite or at risk of weight loss, using cream, butter, cheese and pulses. We discretely observed mealtimes and saw that staff were aware of the needs of people who found it difficult to eat and we noted that they offered sensitive assistance with feeding. They were aware of the importance of offering food at the persons pace, so that they were not hurried. A small number of residents chose to have their meals, particularly breakfast at a different time, or in their bedrooms, to allow them time and space to eat at their own pace. The dining room looked inviting with attractive tablecloths, crockery and condiments. We looked at the menu for the day, breakfast options, cereal, toast, eggs cooked according to preference, fruit juice, hot drinks and this was varied daily. Lunch options were homemade cottage pie, or sausage and mash, with onion gravy. The pudding was lemon curd sponge and custard, stewed apple, ground rice pudding, individual trifles or fruit. The evening meal was assorted sandwiches, jacket potato with fillings or omelettes and supper was a list of options including sandwiches, toast, cheese and biscuits, or sweet biscuits. The meals looked and smelled appetising, and meal times were protected to provide a sociable, enjoyable experience. We asked a sample of people about the food at meal times, and received very favourable comments, food very good and plenty of it, and lots of choice. The registered manager told us that through suggestions at residents meetings a Care Homes for Older People Page 21 of 37 Evidence: kardex of pictures of meals and snacks had been put together. These were very colourful and displayed meals, which looked appetising and appealing. We were shown large print daily menus, which were also being developed, to be laminated and displayed to show daily meal choices. These are excellent initiatives to assist people make real choices for their meals. Care Homes for Older People Page 22 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that any concerns and complaints are listened to and action is taken to look into them, with systems in place to record investigations and outcomes. There are good arrangements in place to safeguard people living at the home from risks of harm. Evidence: We saw that Holly Lodge had an up to date, revised and improved complaints procedure, which was displayed in the reception area and contained in the service user guide. Information supplied as part of the Homes AQAA indicated that the home had received two complaints, over 12 months, which had been investigated by the provider within 28 days, with satisfactory outcomes. The complaints were upheld and resolutions implemented. There were complaint forms to record formal complaints, which were improved and much better for providing detailed information. The responses during the inspection indicated that people were aware of how to raise concerns or use the homes complaints procedure. This demonstrated positive practice and the homes proactive response to peoples experiences and perceptions of the service. We were told that the home had received the complaint of an alleged theft from the home, which was considered under the Safeguard and Protect multi agency Care Homes for Older People Page 23 of 37 Evidence: procedures, with outside agencies taking no further formal action. The registered persons undertook a thorough investigation and proactively implemented rigorous measures. There were no other allegations of abuse of vulnerable persons. There was a copy of Dudley DACHS (Directorate of Adult Community and Housing Services) multi-agency procedures relating to safeguarding vulnerable persons living at the home. The organisations policies and procedures to safeguard vulnerable people were satisfactory and had been reviewed and updated to be in line with regulations and other external guidance. We were given documentary evidence that all staff have been made aware and have been given time to read and understand procedures for the protection of vulnerable adults. The majority of staff had been provided with training, which provided appropriate awareness of safeguarding vulnerable adults and staff were aware of what they needed to do should an incident occur. Care Homes for Older People Page 24 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the decor within this home is good with evidence of improvement through proactive planning and continuous maintenance. The home presents as a safe, homely and comfortable environment for people living there. There are effective systems in place for maintaining infection control. Evidence: Holly Lodge was comprised of two distinct areas, the Old House and the linked New House. The interior of the home was a bright, cheerful and homely. There are attractive, and well maintained gardens, with new garden furniture, which two people, were using to enjoy the warm spring sunshine. The registered manager successfully made a bid for one off funding from the Department of Health to landscape the enclosed front garden, and had provided people living at the home with a more accessible paved area with planters, ornaments and a bird table. She told us that there were plans to have raised planters to grow vegetables as activities and to provide fresh home grown produce for people living at the home. The tour of the building identified that a number of improvements have been made and the program of redecoration and refurbishment was continuing, with the majority of requirements for repairs and redecoration issued at the last inspection completed. Some examples were the small quiet lounge, which had been redecorated, and had new curtains and comfortable chairs. Following the full rewiring of there were new Care Homes for Older People Page 25 of 37 Evidence: attractive chandeliers and wall lights throughout the home. We spoke to a person using the quiet lounge, who told us they loved living at the home, and were very appreciative of the improvements. We also noted that therewas a new call system, with additional call points in communal areas and quieter buzzers, which provided better access and a less intrusive environment for people living at the home. A large number of magnetic door openers linked to the fire system had been installed, which was a positive initiative to improve access for people at the home. We saw that the bathing and toilet facilities had been renovated, redecorated, with new flooring and tiling to provide a pleasant environment, with improved infection control measures. There were also improvements to corridors with the installation of new floorboards and carpets and new brighter lighting installed, creating a light airy and safer environment for people living at home. We looked at a sample of bedrooms with peoples permission where possible. All were attractively decorated and personalised according to individual preferences. The majority have many treasured personal possessions such as family photographs, ornaments and small items of personal furniture. The majority of bedroom had been attractively redecorated to high standards, with new furnishing. Many bedrooms had pleasant views and those on the second floor had magnificent views across the countryside. During discussions with people they told us they approved of the new decorations, especially the bedrooms, toilets and bathrooms. We were told that the home was always clean, warm, and comfortable. The small laundry, located in lower ground floor of the building was well equipped with commercial washers and tumble dryers. The laundry service was generally well organised and the staff demonstrated good standards of infection control. There was a laundry procedure and measures in place for supplies of disposable gloves and aprons to be readily available in the laundry at all times. The homes main kitchen was maintained in very good order, and it was clean and tidy and well organised. We noted that appropriate food hygiene and safety measures were in place, with well kept records, monitored by the registered manager, and Environmental Services. The home had achieved the Dudley MBCs Environmental Health Four Star Food Award for healthy eating and food hygiene. There was also a very positive improvement in that catering hours have been extended to provide cover breakfast times improving availability of care staff to assist people getting up. Care Homes for Older People Page 26 of 37 Evidence: Throughout the home good standards of cleanliness continued to be maintained and there were no discernable malodours during this visit. We received a number of comments, which all gave a similar view, the home always smells nice, cleaners come around every day. There were some minor additional improvements required at this visit, such as the laundry area needed additional attention to the redecorated walls, which had started to peel. This was important to rectify to maintain infection control integrity, especially as the home has someone discharged from hospital with MRSA. The damaged bed base with an exposed area needed to be replaced and bedrails needed attention to ensure they were fitted and maintained in a safe condition. Care Homes for Older People Page 27 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This home continues to maintain stable substantive staffing levels and people receive consistent and excellent standards of care. The staff recruitment processes are generally robust, which means that there are effective safeguards for people living at the home. The organisation and registered manager demonstrate a strong commitment to staff training and development. Evidence: The homes AQAA cited the following as evidence of what they do well, staff are aware of their responsibilities. Warm rapport with service users and visitors. Experienced and qualified staff. Citation PLC approved job documentation. Thorough recruitment processes. Low staff turnover. No use of agency staff. Training offered by qualified outside agencies. Staff ratio to service users needs is high. The improvements over the past 12 months cited were, we have had regular plan to staff meetings, which has resulted in staff being aware of any changes in legislation or problems etc. nearly all staff have attended training in first aid, food hygiene, moving and handling, infection control, adult abuse, medication Administration, fire procedures, dementia. Three members of staff obtained their NVQ at level 2 and one at level 3. Four members of staff are currently working towards their NVQ level 2. Cooks now prepare breakfast, which means there are five members of staff on duty from 8 a.m. to 12 noon to assist service users with care needs. Staff files are properly indexed and all information is up-to-date and relevant. Care Homes for Older People Page 28 of 37 Evidence: We were able to verify the good practices claimed from observations, discussions and examination of samples of records during this visit. We noted that there were 18 people accommodated, with a variety of dependency levels and diverse needs. The registered manager told us that she reviewed staffing levels on a regular basis, taking account of the occupancy and dependency levels of the people accommodated, which demonstrated good practice. Assessment of staffing rotas and information from the AQAA and staff personnel records demonstrated that the home was generally maintaining satisfactory staffing levels. The Home had a stable staff team of 27 people including 24 care staff, domestic staff, 1 gardener/maintenance person, and the Registered Manager and catering staff. Four staff had left the homes employ since in the past 12 months for valid reasons, and there were no staff vacancies at the time of this inspection. We looked at a random sample of staff personnel files, which were satisfactory. The registered manager had continued to demonstrate generally robust recruitment practice, with improved well ordered staff files and essential documentation. We raised one query about an application form without a fully completed employment history, though this person had indicated they had previously worked in a care home. We have recommended that the registered manager sought clarification and additional documentation as necessary. We noted that the organisation continued to demonstrate a strong commitment to staff training and development and had continued to provide all staff with appropriate training to raise awareness and skills to respond to peoples changing needs. We saw evidence that 18 of 24 care staff had achieved an NVQ level 2 care award with new candidates registered for training. We were told that staff annual appraisals had commenced and saw evidence of a formal structured supervision system, with matrix displayed to show dates that all care staff had planned minimum of 6 one-to-one supervision meetings. During discussions it was evident that staff felt supported. The comments received from staff included, good teamwork residents are always well looked after by all staff, good team in home and good management team. Care Homes for Older People Page 29 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager and senior staff provide effective leadership and good clear communication systems. All staff demonstrate good awareness of their roles and responsibilities, which means that people can be assured of excellent standards of care and attention. The systems for consultation at this home are good with ample evidence demonstrating that peoples views about the service are both sought and acted upon. The standard of record keeping and health and safety compliance at this home is good, providing people with safeguards from risks of harm. Evidence: Paula Hubble, the registered manager at Holly Lodge had worked at the home for more than 19 years. She had achieved the NVQ level 4 Award in Management and Care. She had not achieved the RMA (Registered Managers Award) however she stated that both she and the new deputy manager had enrolled as candidates through Care Homes for Older People Page 30 of 37 Evidence: Train to Gain to undertake the new qualification, Leadership and Management, and planned to achieve the award over the next 12 months. It was positive that the registered manager had altered her hours, created a new management team with an additional deputy manager, to achieve sufficient managerial time to develop the staff and service to meet and exceed the Legislative framework and National Minimum Standards. During discussions there was evidence of an open, approachable ethos, which encouraged good communication with people living at the home, their relatives and staff. We saw evidence that the registered proprietor usually visited the home regularly, and whenever he was out of the country for an extended period, he had formally notified the Commission and made suitable arrangements with his partners in the business to undertake Regulation 26 visits and reports regarding the conduct of the home until his return. We looked at the Regulation 26 Reports held at the home and noted that from May 2008 to October 2008 the previous very basic format had been used. Whilst it was positive that an improved expanded format had been used in November 2008 and February 2009, the reports relating to the conduct of the home had not been completed and given to the home on a consistent monthly basis. We also noted that no discernable progress had been made to provide the registered manager with suitable professional support and supervision. We were told that the registered persons had purchased a new quality assurance system through the West Midland Care Association, based on KLORA (Key Lines of Regulatory Assessment) and equality and diversity. We saw evidence of very positive quality audits during this inspection visit, which meant positive outcomes for people receiving the service. There were clear lines of accountability within the home, and through the management structure. We noted that the registered manager had devised and implemented the homes annual development plan for the current year. We saw excellent evidence that the registered manager had used good self auditing systems, and these included monthly audits of areas such as peoples case files, staff personnel files, staffing levels and accidents, incidents and falls, with remedial actions to minimise risks identified. The registered manager and team have continued commendable efforts to involve people living at the home, their relatives, representatives and other community Care Homes for Older People Page 31 of 37 Evidence: stakeholders in the running of the home. We noted that there were regular residents meetings and relatives, with minutes available. The homes survey questionnaires had been distributed to residents and families and stakeholders, with completed forms returned, and results collated and published. We saw evidence that the results had been acted upon in any area where there were concerns or where performance needed improvement. An example was people living at the home felt they did not have an input into choices for meals, though minutes of residents meetings suggested otherwise. The registered managers action was to make sure people living at the home were more aware of food choices with pictures and cookery books discussed at residents meetings, which demonstrated positive action and good practice. We noted that staff meetings were taking place more regularly, with minutes posted on notice boards. The structured formal supervision system appeared to be working well with supervision sessions identifying training needs, personal development and support. This had evident benefits for people living at the home. We noted that people were offered the opportunity to manage their own money if they wished, and the home provided facilities to help keep it safe. We looked at a random sample of balances and records of monies held in temporary safekeeping on behalf of people living at the home, which were accurate, with well documented records of all transactions. We looked at a sample of heath and safety, fire safety and maintenance documentation, which was satisfactory and very well organised. There was evidence that all staff receive mandatory training commensurate with their roles, such as fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training, commensurate with duties undertaken. During the tour of the home we noted two sets of bedrails in use, and though there were risk assessments in place they were not sufficiently detailed. There was insufficient evidence of regular maintenance checks or awareness of the dimensions laid down by the Health and Safety Executive (HSE) for the safe use of bedrails. One set of bedrails had loose fittings causing excessive gaps. Remedial action was taken during the visit. We gave the registered manager details of the HSE website to obtain information and training material. We stressed that replacement pressure relieving mattress must not be used with existing mattress, or alternatively extra height bedrails must be provided. We drew the registered managers attention to the stipulated height above the uncompressed mattress to the top of the bedrails, which must be a minimum of 220 mm. With the pressure relieving mattress in place the height was only 40mm, which presented a serious risk. The registered manager Care Homes for Older People Page 32 of 37 Evidence: assured us that the risk assessments would be reviewed as a priority with appropriate action taken to demonstrate compliance. There had been 23 recorded accidents involving people living at the home in the past 12 months. The registered manager had an effective system for auditing, analysing and evaluating accidents involving residents, with effective measures implemented. Care Homes for Older People Page 33 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 34 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 37 13 The registered persons must 01/05/2009 implement management systems to ensure the safe use of bedrails, which includes correct fitting, rigorous risk assessments, diligently followed, documented checks and staff guidance and training relating to bedrails. This is to safeguard the health, well being and safety of people living at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 It is recommended that information about the complete range of fees should be included in the service user guide to give people comprehensive information about the service to help them make decisions about the choice of home. It was recommended that moving and handling risk assessments should be expanded to include all transfers and signed by the assessor. Page 35 of 37 2 8 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 3 9 It was recommended that any changes to medication regimes should be reflected in the persons updated care plan. It was recommended that the homes good practice of regular medication audits should be enhanced, identifying what remedial action had been put in place to prevent medication errors. It was recommended that a key worker system should be introduced to enhance the quality of individual person centred care for people living at home. It was recommended that the development of menus in formats suitable to the peoples capabilities be completed, to assist them to make realistic choices. The registered provider must ensure that the registered manager has access to regular documented professional supervision, support and development. The registered manager must be supported to achieve the Leadership and Management Award within an agreed timescale. 4 9 5 9 6 15 7 31 8 31 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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