Inspection on 13/06/06 for Halcyon Days

This inspection was carried out on 13th June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Halcyon Days 03/02/06

Halcyon Days 14/09/05

Halcyon Days 20/04/05

Halcyon Days 09/12/04

Halcyon Days 31/08/04

Halcyon Days 11/03/04

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

CARE HOMES FOR OLDER PEOPLE Halcyon Days The Old Rectory Church Lane Graveley Nr. Stevenage Hertfordshire SG4 7LU Lead Inspector Jeffrey Orange Key Unannounced Inspection 13th June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halcyon Days Address The Old Rectory Church Lane Graveley Nr. Stevenage Hertfordshire SG4 7LU 01438 315588 01438 312587 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) Karlamain Limited Dawn Richmond-Cook Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 3rd February 2006 Brief Description of the Service: Halcyon Days is registered to provide care and accommodation for up to 33 older people. It is a detached, late Victorian building that has been sympathetically extended to create the current home. Bedrooms are located on the lower ground, ground, first and second floors, and are mainly offered for single occupation. There are two lounges, a reception seating area and two dining rooms. The kitchen and hairdresser’s room are located on the ground floor. The bathroom, shower room, and toilet facilities are adequate to meet the requirements of the service users accommodated. The office, laundry and extensive storage area are located in the lower ground floor. The home stands in three acres of mature landscaped grounds and offers fine views over the surrounding countryside. It is located in a quiet rural area on the outskirts of the village of Gravely and the towns of Stevenage and Hitchin are easily accessible by public transport. Prospective service users are provided with a copy of the home’s Statement of Purpose, Service User’s Guide and the latest copy of the home’s newsletter. The latest inspection report from the Commission for Social Care Inspection is made available on request. Fees at 13/6/06 range from £400-£525 per week. Additional charges are made for hairdressing, chiropody, newspapers and personal toiletries. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been compiled following a site visit to the service, which lasted approximately six hours. It provided an opportunity to talk to service users about their experience of living at Halcyon Days and also to talk with the members of the staff team. During the visit a range of records were seen and very positive and helpful discussions were held with the manager about plans for the future of the home and its activities. This report also draws on our previous experience of the home and on any information that we may have received about it since the previous inspection in February this year. What the service does well: What has improved since the last inspection? The one requirement and one recommendation made following the previous inspection have both been met in full. The requirements and recommendations made following an inspection by the Commission for Social Care Inspections’ pharmacy inspector in January have also been met in full. Several members of the staff team mentioned the positive benefit experienced over recent months with increased investment in equipment and staff training; “Fabulous changes” was how one staff member put it. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 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 the following standard(s): 1 3 4 (Standard 6 does not apply to Halcyon Days) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Anyone considering Halcyon Days as a home, either for themselves or for someone else, are given the necessary information and opportunity to visit the home, so that they can make an informed decision. The registration position in respect of residents who have been admitted with physical disabilities (who are for example registered blind ) must be clarified. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which have recently been reviewed and updated. The assessment process seen in care plans is thorough and comprehensive, however at least two residents have been admitted who are registered blind although the home is not currently registered under the physical disability Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 9 category. This needs to be regularised, as it is important that a home’s registration reflects its ability to fully meet the needs of anyone admitted. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The standard of personal care provided is good and residents’ health needs are met appropriately. The standard of record keeping relevant to resident’s care needs and how they are met is generally good, care plans and risk assessments are reviewed and updated regularly to make sure they continue to reflect the needs of resident’s as they change. Medication policies and procedures are essentially sound and provide for the safe administration of medication when this is carried out on behalf of residents. EVIDENCE: Care plans and risk assessments were seen and included evidence of review and updating to keep them accurate and effective. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 11 Personal care was seen being given in appropriate and respectful ways, and the feedback received from residents about the standard of their care was very positive. “ All the carers are very good” was a typical comment by residents. Care plans include evidence of the involvement of health care professionals; one resident was observed being taken to hospital from the home during this visit. Medication records were checked and were generally satisfactory, with only minor shortfalls found. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are able to maintain contact with family and friends and this is both encouraged and facilitated by the home. Choice can be exercised in many areas of the home’s routines, this needs to be kept under review to ensure that all residents feel empowered to take advantage of choice when it is offered. The range and scope of activities available in the home is currently under active review. EVIDENCE: The printed activities programme for the home does not fully reflect or do justice to what actually takes place and needs to be developed in scope and in line with current good practice. Very positive discussions were held with the manager and activities organiser. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 13 The dining room is a particularly attractive environment for mealtimes, comments about the food were mixed, although on balance mostly positive. The challenge of ensuring that residents feel able and empowered to take advantage of choice when it is offered was discussed with the manager. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The complaints policy and procedure in place, staff training in and awareness of adult abuse issues should provide confidence to residents and those concerned for them that the home offers a safe and protective environment for its residents and that any complaint or concern will be listened to and dealt with appropriately. EVIDENCE: Regular resident’s meetings are held and the home’s complaints policies and procedure are well publicised. Staff training records show that adult abuse awareness training has taken place. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19 20 23 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home provides its residents a comfortable environment that is clean and well maintained. Residents are able to make their own rooms reflect their interests and taste by using items of furniture, pictures and ornaments brought into the home with them or acquired after admission. The grounds of the home offer an exceptionally pleasant facility for those residents who like the open air. EVIDENCE: A maintenance person is employed to deal with routine maintenance issues. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 16 A plan is being drawn up to set out priorities and timescales for work that has been identified as being required on the premises and environment. (A copy should be sent to the CSCI) “Aren’t we lucky with these grounds” was the comment made by two people sitting out and enjoying the sun during this visit. Several residents’ rooms were seen (with their permission) during this visit, and each included items of furniture and ornaments etc that they had brought with them to enable their rooms to reflect their own history, taste and personality. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The numbers and skills of the staff are adequate to provide a good standard of care. Recruitment practice is robust and provides protection for residents. EVIDENCE: Staff rotas were discussed with the manager and are at least at previously agreed levels. Staff training files were seen and members of the staff team were interviewed. All had noted an improvement in the amount of training available. Recruitment records were seen for recently recruited staff and were seen to include all the required information. Although one resident thought that the staff “have too much to do”, the care outcomes seen, and the overwhelming comments of residents were positive. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is well managed and policies and procedures are in place to protect those who use the service or work in the home. A robust, structured system of quality assurance is in place to monitor the quality of the service, as it is experienced by residents. EVIDENCE: Discussions with the manager were robust and open and provided evidence of her commitment to the home, its residents and her staff. The home is using a structured format to achieve a very robust quality assurance procedure, which includes resident’s and relative’s surveys. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 19 Satisfactory supervision frequency was confirmed with staff and from records seen. The home’s front door is not kept closed and locked at all times. This should be risk assessed to ensure that the security of the home and resident’s is not compromised unacceptably. Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 20 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 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 3 X 2 Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 21 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. 1 Standard OP4 Regulation 14 16 18 23 Requirement The Manager must submit to the Commission an application for the variation of the home’s registration in respect of any named individuals whose care needs arise principally from their physical disability and/or must satisfy the Commission that their needs can be fully met by the specialist staff training, equipment, facilities and activities available in the home. In order to maintain the standard of medication practice in the home, the manager must ensure that when gaps in medication administration records are found or where there is inconsistent recording practice or medication is not dated on opening, then appropriate action is taken and recorded. The practice of leaving the front door open and/or unlocked must be reviewed and risk assessed to ensure that this does not represent an unacceptable security risk for residents. This assessment must be recorded and any action identified as a DS0000019403.V299843.R01.S.doc Timescale for action 30/06/06 2 OP9 13(2) 13/06/06 3 OP38 13(4) c 13/06/06 Halcyon Days Version 5.2 Page 22 result must be taken. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The home’s activities programme should draw on current good practice, make use of available research and examples in other homes and be person centred so that provision is individual as well as collective. The manager and her staff team should keep the home’s routines under review, to assess how choice is offered, to ensure that residents feel empowered to exercise available choice in line with their own preferences. A copy of the maintenance schedule, currently being drawn up by the manager for the operations manager should be sent to the CSCI for their records. 2 OP14 3 OP19 Halcyon Days DS0000019403.V299843.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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. 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