Inspection on 24/05/05 for Croxley House

This inspection was carried out on 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Croxley House 12/06/07

Croxley House 21/06/06

Croxley House 09/12/05

Croxley House 10/11/04

Croxley House 11/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Croxley House Croxley Green Rickmansworth Hertfordshire WD3 3JB Lead Inspector Angela Dalton Unannounced 24 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Croxley House Address Croxley Green, Rickmansworth, Herts, WD3 3JB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01923 775 134 01923 897 908 Greensleeves Homes Trust Mrs T Whitbourn CRH Care Home 33 Category(ies) of DE(E)-5, OP-33 registration, with number of places Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Room 21 (8.78 sq m) is to be used only for the purpose of short stay respite care. It will not be permitted for this use after 1.4.07 (date implemented 29/04/03). 2. Room 31, previously used as a staff sleeping-in room, is now registered for residential use (date implemented 29/04/03). 3. Alteration to Room 22 will not take place whilst the present occupant remains in that room (date implemented 29/04/03). 4. Room 22 (20.83 sq m) will be altered to allow for the increase in size of room 21 to meet the 12 sq m requirement (date implemented 29/04/03). 5. Rooms 15, 17 and 31 be designated as suitable for couples who through positive choice wish to share a room. A max. of 2 rooms to be used at one time (date implemented 29/04/05). 6. The home may accommodate five named service users who have a diagnosis of dementia. The manager must inform CSCI when any of the five service users permanently leaves the home for any reason (date implemented 12/01/05). Date of last inspection 10 November 2004 Brief Description of the Service: Croxley House is a detached two-storey red brick Georgian dwelling house with slated roof built about 1770 with several later additions. It has been extensively refurbished and converted for the residential care of older people. The home provides for up to 31 service users in single rooms, all of which have en-suite facilities. There are three rooms that are available for couples to share but only on a positive basis and with the maximum overall occupancy of 33 service users. One room is below the recommended minimum size standard and is used only by agreement for short stay respite care. The home has two main lounges and a separate dining room. The kitchen is completely stainless steel equipped with freezer and refrigerated food storage. The home’s laundry is equipped to handle all the requirements of the home. Croxley House has its own access driveway across The Green and stands in immaculately maintained grounds with beautiful views across The Green and surrounding woodland and farm countryside. There is a working greenhouse and summerhouse at the rear of the home and the pathway around the garden has a single handrail for support. The garden houses an aviary and there is a fish tank, budgies and cats within the home. Whilst the home occupies a rural setting, it is but a few minutes drive from the towns of Watford and Rickmansworth. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two inspectors from 11am to 4pm. Care was observed to be delivered to a high standard. Clothes are beautifully laundered and the pride that staff take in this task is evident. Service users spoke positively about the home and the staff team. Lunch was sampled and was hot and tasty. Overall the inspection was positive but this was marred by the poor administration of medication. A previously made requirement regarding recruitment documentation has been carried forward. What the service does well: What has improved since the last inspection? What they could do better: The manager still has no deputy manager to assist in the running of the home. The recruitment of a deputy would assist the manager to spend more time in the office and deal with issues that staff and service users raise at an interim level. Recruitment records and medication continue to require attention. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Service users receive adequate information about the home. Care pans do not consistently identify how individual needs are met. EVIDENCE: The home does not provide intermediate care. A copy of the statement of purpose is on display in the reception area and is available to service users and their families. The home manager conducts assessments and they form the basis for the development of the care plan. Individual needs are identified and a recommendation has been made. This is because some care plans describe how needs can be managed and met but some lack this guidance. There must be consistency in recording how service users’ care needs can be met. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Health and personal care received is based on individual needs but elements require improvement. Staff could better observe service users dignity. Service users are put at risk by poor medication practise. EVIDENCE: Care plans fully identify service users needs but as discussed earlier further expansion is needed to identify how they are met or managed. An enforcement notice will be served regarding medication. A member of staff was observed to give medication after signing the medication record sheet. This was then altered as the service user refused medication. An enforcement notice was served regarding medication following the previous inspection in November 2004. Lunch was observed and although staff were sat to assist there was little interaction or engagement between staff and service users. A recommendation has been made as this does not observe service users’ dignity. Individual wishes regarding funeral plans should be reflected in care plans. The manager plans to assist a service user to purchase a dress from the internet as they find shopping in a store too overwhelming. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Service users have access to activities and meals that meet their requirements. EVIDENCE: Both service users and visitors spoke highly of the home. Regular activities take place both within the home and in the form of outings. On the day of inspection some service users had been out to look at a local beauty spot where bluebells were in flower. During the afternoon a visiting saxophonist was playing in the lounge. As stated earlier, food is of a high quality and service users are asked for regular feedback to ensure their preferences are observed. Service users assist with laying the table and clearing up following meals. A menu is on display to ensure service users are informed about meal options. A summer ‘Strawberry Fayre’ is being organised which has become an annual tradition. Service users can sell crafts that they have made and it raises funds for the home. This will be followed by collaboration with a local music school in the form of an open air concert. This provides a social event for service users and their families as well as the staff team. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Service users are enabled to complain. EVIDENCE: There is a copy of the complaints procedure on display in the foyer of the home to inform service users and their visitors how to complain. Staff had an awareness of the Whistle blowing procedure and knew how to report any concerns about service users’ welfare. Service users who wished to do so were supported to vote in the recent election. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The environment meets the needs of the service users. EVIDENCE: The home was clean and odour free. Infection control policies were observed. Service users have lockable rooms and lockable space to store valuables or medication where necessary. Facilities meet service users’ requirements. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Staff screening is inadequate. Staffing levels meet service users’ needs EVIDENCE: Service users spoke highly of staff and were complementary about their kindness and meeting their requests. Recruitment documentation again continues to fall short of the required checks. Overseas staff files were incomplete and evidence was not in place to demonstrate that service users are safeguarded. A requirement has been made. Regular training is provided to ensure that staff are able to meet identified needs of service users. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37,38 Service users do not have evidence of financial transactions. Senior management do not gain a true impression of the home during their visits. EVIDENCE: The manager is experienced in managing a care home. As stated earlier she would be better supported if a deputy manager were employed. Service users are undoubtedly at the centre of the home and feel happy to raise any concerns with the home manager who meets regularly with them to canvas opinions about the home. A requirement has been made to provide service users with a receipt for transactions made with visiting professionals to the home e.g. hairdresser and chiropodist to evidence payment. It is currently recorded in a hardback book without a receipt. Monthly visits made by the proprietor’s representative must be unannounced but staff are currently made aware of the impending visit. A Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 15 true impression of the home is therefore not reflected. Some doors are wedged open and this practise must cease to ensure service user safety. Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 2 3 2 2 Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 17 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP4 OP7 OP9 Regulation 15(1) 12(1)(a) 13(2) Requirement Documentation must state how identified needs are met or managed (e.g. mobility) Medication must not be signed for prior to administration to service users AN ENFORCEMENT NOTICE WILL BE SERVED Service users must be provided with a receipt to accompany financial records detailing transactions Proprietors monthly visits must be unannounced Door wedges must not be used and a safe alternative must be employed Overseas status must be checked with verification recorded from the Home Office. Required documentation must be evidenced in personnel files e.g. passport A REQUIREMENT RELATING TO RECRUITMENT WAS MADE AT THE PREVIOUS INSPECTION Timescale for action 30/06/05 30/06/05 3. OP35 13(6) 30/06/05 4. 5. 6. OP37 OP38 OP29 26 13(4)(c) 19(1) Schedule 2 30/06/05 30/06/05 30/06/05 Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP10 OP11 Good Practice Recommendations Staff should engage with service users when assisting with meals on a one to one basis Care plans should contain service users funeral wishes Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Croxley House I52 s19318 Croxley House v227631 240505 Stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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