Care Home: Holly Tree Lodge Care Home

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What the care home does well A visitor told us that people in this home are well cared for by a committed and friendly care team. He said that staff treat people with dignity and respect. Staff are well trained and have a good understanding of people’s needs and wishes. They encourage people to make their own choices and decisions and to be as independent as possible. There are good systems in place to make sure people are protected, including staff training, risk assessments and policies; people who use this service have told us that they feel safe living in the home.Holly Tree Lodge Care HomeDS0000034136.V378630.R01.S.docVersion 5.2 What has improved since the last inspection? Since the last inspection, care plans have been improved and people are now involved with their care plan or if they are unable to do this, a relative or friend acts on their behalf. People who live here now have a key worker who sees to the specific needs of those residents that they work with. Care plans also reflect new laws relating to residents health and general welfare, as well as their ability to make decisions for themselves. Forms which are used to assess peoples needs have been updated and show any significant or specialist areas of care which are required. Medication is given safely with an accurate record made of when medication was given. Staff working closely with people by explaining what is in their care plans and what changes they would like to make in them. Residents and relatives are able to see a senior nurse or the deputy manager when they so wish and voice their opinions or seek advice. What the care home could do better: There were no requirements or recommendations made as a result of this visit. We made some suggestions to help make things better. We said that an activities organiser should be employed to ensure that all those people in the home are assessed and receive activities of their choice. We also said that the corridor carpet in the dementia unit should be replaced as it looked stained. Before this visit was finished the provider confirmed that the above suggestions would be carried out in the New Year. Key inspection report CARE HOMES FOR OLDER PEOPLE Holly Tree Lodge Care Home 3 Eastgate Scotton Gainsborough Lincs DN21 3QR Lead Inspector Doug Tunmore Key Unannounced Inspection 8th December 2009 09:00 DS0000034136.V378630.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Lodge Care Home Address 3 Eastgate Scotton Gainsborough Lincs DN21 3QR 01724 762537 01724 764469 htlcare@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Staywood Limited Mrs Pamela Ellen Timmins Care Home 40 Category(ies) of Dementia (17), Dementia - over 65 years of age registration, with number (17), Learning disability (1), Old age, not falling of places within any other category (22), Physical disability (1) Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users in category DE must be aged 50 years and over in Holly Tree Lodge Residential Care Home The bed in Holly Tree Lodge Residential Care Home in category LD is for a service user named in the Notice of Proposal to register dated 21st October 2004 To be able to admit into Holly Tree Lodge Residential Care Home the person of category PD named in Variation Application Number V36870 dated 17th November 2006 No person to be admitted to Holly Tree Lodge Residential Care Home in categories OP, DE, DE(E), LD or PD when 40 persons in total of these categories/combined categories are already accommodated in this home. 18th March 2009 Date of last inspection Brief Description of the Service: Holly Tree Lodge provides nursing and personal care for up to 40 people, 17 of whom who have dementia requiring nursing care and are accommodated in a new purpose built unit. On the day of the inspection there were 35 people living in the home. The purpose built, single storey unit for people with mental illness of old age provides accommodation for 17 people in 15 single bedrooms and one double room. All bedrooms are en-suite with 2 having showers. This unit also has one lounge and one dining room. There is a garden area leading off from the lounge. Accommodation in the main building is on two floors and provides 4 double bedrooms and 15 single bedrooms, none of which have en-suite facilities. Accommodation on the first floor is served by a shaft lift. There are 2 lounges and a dining room. The home is also set in its own grounds. Twenty two people aged 65 years and over who require nursing care or personal care and one person aged 55 years who has a learning disability are accommodated in the main building. There are car parking spaces at the front of the home. The fees at the inspection visit on the 08/12/2009 ranged from £360:00 to £785:30 each week. Extras are for hairdressing, chiropody, personal newspapers and magazines. The provider makes no charge for escorting residents to hospital. Information about the home can be obtained from the Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.2 Page 5 manager of the home. The service user’s guide is available from the manager and is kept in the office. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use this service experience good quality outcomes. This was an unannounced visit and it formed part of a key inspection, focusing on key standards which have the potential to affect the health, safety and welfare of people who use the service. Throughout this report the terms we and us refer to the Care Quality Commission (CQC). The visit took into account previous information held by us including the previous inspection report, their service history and records of any incidents that we have been notified of since our last visit. Before we made our visit the manager had returned the Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. The Commission are trying to improve the way that we engage with people who use services so that we gain a real understanding of their views and experiences of social care services. The main method used to carry out the inspection is called case tracking, which includes following the care of a sample of people through their care records and assessing their care. We spoke with two people who use the service. We spoke with one member of staff and the handyman. We spoke to one visitor as part of the information gathering process. The deputy manager and the operations director was present throughout this visit and they were kept informed of the general outcomes. What the service does well: A visitor told us that people in this home are well cared for by a committed and friendly care team. He said that staff treat people with dignity and respect. Staff are well trained and have a good understanding of people’s needs and wishes. They encourage people to make their own choices and decisions and to be as independent as possible. There are good systems in place to make sure people are protected, including staff training, risk assessments and policies; people who use this service have told us that they feel safe living in the home. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 3 Standard 6 is not applicable. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People received a comprehensive assessment, which resulted in their needs being met. EVIDENCE: Residents and their families had been involved in their admission to this home and assessments are carried out by a skilled and trained member of staff. We looked at three care plans and found that some assessments were also available to the home from health care professionals as well as social workers detailing the needs of those residents. The files of those residents who were being case tracked had admission forms which were fully completed, the entries referred to specific and significant/specialist areas of care, which were Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 10 needed. The deputy manager told us that prospective residents are encouraged to visit the home before they make a decision to come and live there. People are also written to by the provider confirming whether their needs can be met by the home or not. We looked at care plans which had assessments about people’s needs and wishes in areas such as mental health, physical health, social preferences, medication and end of life arrangements, as well as nutrition. A relative told us that he had enough information about the home prior to his relative’s admission. He also said that he was fully involved in the admission process and the staff couldn’t do enough for his wife. The home does not provide intermediate care. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people are being met in a safe and dignified way. Robust medication procedures keep people safe. EVIDENCE: The care plans showed that accident reports and body maps are used for the mapping of any cuts or abrasions to residents. We also looked at risk assessments in resident’s files, which were available, giving details of various risks concerning resident’s health care needs. It was found that risk assessments and permission statements, for people who have the use of a wheelchair in which straps were in use, was documented. Best interest meetings are held with residents, their families and their doctor regarding their care needs and those issues which limit their independence. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 12 Peoples care plans also confirmed that health care professionals visit the home when required by the residents. Files showed that people are actively involved in their care plans and had signed them. Staff now work as key workers to individual residents and go through care plans with residents and their families. We found that care plans are now kept in peoples bedrooms so that they can look at them when they so wish. We were told by a visitor that he was involved in his wife’s care plan and had attended reviews at the home. He also said ‘my wife has a special mattress and she is turned over by the staff every two hours. They (the staff) have cleared up previous pressure sores’. We were told by a resident that she had seen her doctor on the morning of this visit. She also said that ‘staff are sensitive and gentle with me and when I have a shower they close the door’. One of those care plans which we looked at made reference to new laws about decisions that may affect peoples lifestyles. Care plans were also personalised with residents stating the type of care that they want. The deputy manager said that training is to take place to ensure that all staff are aware of how to assess peoples needs and record this in care plans. She further added that nearly all care plans are up to date. Care plans also showed that people are asked if they wish to be checked at night or not. Those care plans that we looked at showed that peoples dignity and privacy was to be maintained and how this was to be carried out. A record is also kept on how residents wish their privacy and dignity to be maintained. One carer told us that she knew about maintaining the privacy and dignity of residents and treating them with respect. She was also very knowledgeable concerning the general care and welfare of people living in this home. It was noted that staff treated people with respect during this visit and engaged residents’ in a way which was mindful of their dignity. Medication sheets were seen by the inspector and it was found that an accurate record of medication was kept of medicine given on that day. None of the people at this home are able to self medicate at this time. Only nurses give medication and the providers training file evidenced that four nurses are to undertake further training in the administration of medication. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A limited range of activities is available to residents, which suits some of their needs. Meals provided are well balanced and take into account personal preferences. EVIDENCE: We looked at the activities notice placed in the entrance to the home, which showed that a variety of activities are to take place. Activities were arranged for September, October, November and December in which eight entertainers have been booked. There is to be a Christmas Fayre on December the 5th and on the 8th December carol singers, mince pies and mulled wine will be available and relatives and friends are invited. Religious holidays are also celebrated and visitors are encouraged to join in. We were told by a resident that she had been to church and the vicar comes to the home on a monthly basis. She confirmed that there is to be a service held by the vicar on the day of this visit. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 14 She also said that she reads books, watches television and sometimes joins in with activities. She confirmed that she has visitors who are made welcome. The deputy manager told us that a resident had decorated the Christmas tree and she likes to read the papers, does the crossword and receives a phone call from her son on Mondays. There is no activities organizer and the deputy manager confirmed that activities are undertaken by staff. We looked at a number of life history photograph books, which a number of people have. They have been put together by care staff and visitors showing the lives of people both in words and photographs. In the last visit to this home, a visitor confirmed that birthdays are celebrated and that the staff put on a special buffet for their relative and all the family came. All visitors confirmed that staff are always friendly and welcoming when they visit. People told us that they enjoy the food at the home and that they have a choice. Observations made were that the meals looked wholesome and well presented. Residents seemed to be enjoying their meal. There were ample staff to support residents with their meal, which was undertaken in a dignified and caring manner. The home has been awarded a five star Food Safety Award. A visitor confirmed that at his request he feeds his wife every lunch time in the privacy of her room. He stated ‘she is on a special diet and is now gaining weight and is more comfortable in her own room, were she eats really well’. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Clear policies, training and a responsive and caring staff team protect people. EVIDENCE: We were told by a carer that she knew what safeguarding was and what action should be undertaken if abusive practice came to her attention. She was aware of the types of abuse and what forms it could take. The carer was aware of the policies and procedures, which she has read. She confirmed that she had undertaken safeguarding vulnerable adults training. The carer also said that she had undertaking level 2 and 3 in a National Vocational Qualification in looking after elderly people. The provider has the appropriate adult protection policies and procedures regarding the safeguarding of residents. We looked at three personnel files of staff that had recently been employed and found that a robust approach was undertaken regarding carrying out checks on all new staff. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 16 We looked at the complaints file and found that two complaints have been made and documentation was available to show that these complaints were being addressed. We were told that there have not been any safeguarding vulnerable adults’ issues since the last visit. None of the visitors or people seen on the day of the visit expressed any concerns to the inspector. One visitor told us that he knew how to make a complaint and that he felt comfortable in approaching staff. He further stated that ‘the staff are ever so friendly’. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a comfortable and clean environment that meets their individual needs. EVIDENCE: We looked at the maintenance book, which showed all those tasks undertaken relating to maintaining the fabric of the home. The maintenance man confirmed that there is a rolling programme of refurbishment. On the day of this visit he was busy removing carpets from two rooms in preparation to refit new carpets. The carpets in the corridors in the dementia unit were seen to be discoloured. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 18 There are patio doors in the dementia unit, which open onto a small secure enclosed garden where residents who are able are encouraged to wonder in and out freely, under supervision, weather permitting. People told the inspector that they are more than happy with the environment and feel safe and secure. Risk assessments were completed for the use of bedrails. Information was also available for staff on how to use this apparatus safely. At a previous inspection one resident stated that the bedrails are very good and stop her from falling out of bed. People told us that they liked their rooms and had brought memorabilia with them when admitted. They also said that their rooms are kept clean, dusted and tidy and there are no unpleasant smells. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately staffed with employees who were experienced, competent and trained to care for older people. EVIDENCE: Previous visits made on the 18/03/09 found that staff had been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults, to all carers as part of their induction training. The training profile for 2009 was seen and showed that care staff are encouraged to train to NVQ level two and 3. In 2009 carers had undertaken training in moving and handling, fire safety, MRSA relief, food hygiene and first aid training. A carer confirmed that she had undertaken training at the home in the ten years that she has worked there. The carer told us that she had undertaken, some the training mentioned above and dementia training, health and safety, first aid, safeguarding vulnerable adults, induction training and infection control. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 20 The homes duty rota was seen and it was found to be an accurate record and showed that adequate staffing levels are maintained to meet the needs of residents. The carer told us that ‘there is enough staff at the moment, which gives us time to talk to residents. We were told by a resident that there are plenty of carers on duty and if I use by buzzer they come very quickly’. A visitor told us that ‘staff seem to be looking after my wife very well. I have had advice from them on how to feed my wife and I watched them as they did a demonstration for me. They never raise their voices’. Care staff were observed carrying out their duties in a sensitive and caring manner. Both residents and visitors felt that there was enough staff to meet their needs. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33, 35, 37 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good risk assessments help ensure the safety of residents when using aids and adaptations. People’s valuables are protected due to robust procedures. EVIDENCE: We were told that the deputy manager has been appointed as acting manager until the provider appoints a new manager. The operations director told us that ‘we have advertised in various journals and will be interviewing prospective managers as they apply’. He also stated that the current acting manager has a lot of experience, both as a manager prior to working at this home and as a current deputy manager at this home. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 22 The home conducts an in house quality assurance (QA) report. Relative’s surveys were seen and found to be positive in respect to the care provided to residents. The last residents/visitors meeting was held on the 23/01/08; there was a small attendance and no concerns were raised. We looked at two resident’s valuables/clothes form, which showed that a full record had been made of both residents belongings. The deputy manager stated that they also photograph any valuables and this information is also kept in peoples files. We looked at a sample of residents financial records at the last visit in March 2009 and showed that finances for people are kept in a safe place and there is a clear system of accounting in place. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. The homes pre-inspection questionnaire evidenced that fire alarm, fire drills and emergency lighting checks have been undertaken to ensure the safety of people. A carer confirmed that she knew what to do in the case of a fire. Health and safety policies were well documented and up to date. The homes AQAA evidenced that maintenance and service histories of all aids and adaptations are carried out. Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x 3 3 Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holly Tree Lodge Care Home DS0000034136.V378630.R01.S.doc Version 5.3 Page 25 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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