Inspection on 20/04/05 for Halcyon Days

This inspection was carried out on 20th April 2005.

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 13/06/06

Halcyon Days 03/02/06

Halcyon Days 14/09/05

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 7LY Lead Inspector Neil Fernando Unannounced 20 April 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. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Halcyon Days Address The Old Rectory, Church Lane, Graveley, Nr Stevenage, Hertfordshire SG4 7LU 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) 01438 315588 01438 312587 Karlamain Limited Mr Graham V Jukes CRH PC 33 Category(ies) of OP - Old Age - 33 places registration, with number of places HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: That no more than three out of five large bedrooms may be used to provide shared accommodation and then only through positive choice. Date of last inspection 09 December 2004 Brief Description of the Service: Halcyon Days 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. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection for the year 2005/6 under the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The last inspection was carried out on 9th December 2004. Halcyon Days is a residential care home owned and managed by Karlamain Limited. It is situated in a quiet rural area, on the outskirts of the village of Gravely. The building has been extended, in recent years to accommodate up to 33 elderly people. At the time of the visit, there were twenty eight service users in residence. The unannounced inspection took place over half a day in April 2005. All of the National Minimum Standards assessed on this occasion bar two, have been achieved. Ten service users and six staff members including the Deputy Manager and one of the Owner/Managers were spoken to, in order to seek their views regarding the quality of life for residents at Halcyon Days. What the service does well: The arrangements to enable service users and their relatives the opportunity to visit and make an informed decision about the facilities offered at this establishment is managed very well. The process for identifying and reviewing health and personal care needs, involving the service user, relatives and professional where appropriate, appears to be effective. Residents’ assessed needs including specialist requirements are being addressed satisfactorily. The level and variety of social and recreational activities is satisfactory and service users are actively encouraged to maintain contact with family, friends and significant others. Information on how to raise a concern is well publicised and service users are being empowered to make a complaint if they are dissatisfied with any aspect of the service. There are well-established systems in place to ensure that service users are protected from harm. Residents interviewed expressed a high level of satisfaction with respect to the quality of service delivery. The environment continues to be well maintained and furnished. Health and safety issues are being attended to. The day and night staffing arrangements remain satisfactory. The training needs of staff are being identified and addressed. The members of the management team are supportive and competent to manage this establishment. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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 HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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) 2, 3 and 5. Standard 6 is not applicable. Prospective service users and their relatives/friends are able to make an informed decision about the facilities offered at Halcyon Days. EVIDENCE: The case files for six service users were examined and these provide comprehensive details of the completed pre-admission assessments undertaken by the Deputy Manager, for both funded and non-funded placements. The comprehensive assessment of needs for the prospective resident ensures that the home only admits service users whose identified needs are achievable. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 9 Records viewed and information gained from four service user and the Deputy Manager provide evidence that prospective residents and their families/friends are actively encouraged to visit the home before reaching a decision that the facilities offered are suitable for them. Two of the current service users confirmed that they and their family had had the opportunity to visit the home to assess the facilities offered, prior to moving in. However, the Manager makes the final decision, based on the identified needs of the prospective resident, whether a suitable placement could be offered. There is documentary evidence to show that each service user and/or relatives is given a copy of the terms and conditions at the time of the admission or soon after. The contract specifies a trial period to enable the new service users experience the services provided at the home. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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 standard(s) 7, 8 and 10 Service users’ needs and requirements, including health and personal care are being identified and addressed in a holistic manner. The care planning and review process is effective and service users’ participation is beneficial to them. Service users are positive regarding the manner their needs are being addressed. EVIDENCE: Based upon the pre-admission assessment, an initial care plan is formulated. Care plans are drawn up involving service users, their relatives, staff members and outside professionals whenever possible. Evidence shows that staff members record relevant development including the care given to service users. Monthly reviews of care plans are being carried out satisfactorily. Information gathered from residents, staff members, care plans and case files indicate that the needs of service users are being identified and addressed satisfactorily. Records show that residents are registered with a local GP of their choice who visits as and when required. The District Nurse also visits as required. The outcome of the Doctor and District Nurse’s visits is well documented. Advice on nutrition can be obtained from the Nutritionist. Other professionals, service users have access to include Dentist, Optician, Audiologist, Podiatrist and HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 11 Community Psychiatric Nurses as required. Residents expressed a high level of satisfaction in the manner their health care needs are being addressed. Service users stated that their care is provided in a dignified and respectful way. Residents were dressed in fresh and appropriate clothes and staff members were seen to interact with them, in a manner conducive to good practice. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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 standard(s) 12, 13 and 15. Service users’ interests, expectations and aspirations are being sought by staff and fulfilled as appropriate. The level and variety of social and recreational activities facilitated provide an adequate level of stimulation for residents’ general wellbeing. Their culinary likes and dislikes are taken into account and dietary requirements are being appropriately met. EVIDENCE: Service users who decide that Halcyon Days is the right home for them appear to be well informed of what they can expect, prior to their admission. Service users are pro-actively encouraged to maintain their social, cultural, religious and recreational interests as evidence through the sample of care plans viewed. There are a number of visiting Ministers of religion who are invited by individual service users. Residents spoken to generally expressed satisfaction with respect to the level and variety of social and recreational activities facilitated. Relatives are encouraged to visit the home at any time and are always made welcome - as verified by service users spoken to. Many service users retain several past contacts, from whom they receive visits. Residents are able to entertain their visitors in the communal areas, the grounds or their own bedroom, if they so wish. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 13 The menu seen provided for a nutritious and varied diet. The main dining room has large windows, which allow plenty of natural light. It is comfortably laid out and provision is made for service users to take their meal in their own room if this is preferred. Most residents prefer to dine with a group of service users with whom they have made friends or identify with. The menu is discussed with service users to accommodate individual choice and preference. An alternative meal is provided if a resident decides they do not want the meal offered on the day. The menu of the day is appropriately displayed and staff members seem to also routinely inform residents about it. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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 standard(s) 16 and 18. The complaints procedures are known to service users, which empower them to raise any concern they may have about the quality of service delivery. Complaints would be taken seriously and addressed speedily. The training of the staff team on the protection of vulnerable adults and the effective implementation of care and staff monitoring systems offers adequate protection to service users. EVIDENCE: Staff members interviewed demonstrated a good understanding of the complaints procedures. Information on how to make a complaint is also included in the home’s statement of purpose and service users’ guide. Residents felt able to make a complaint if they are dissatisfied with any aspect of the services they receive. The home maintains a complaints record book, which indicates that there have been no complaints made to the home since the last inspection on 9.12.04. The home has procedures on Adult Protection and “Whistle Blowing”, and a copy of the DOH guidance ‘No Secrets’ is available to the staff team. Staff members interviewed demonstrated an understanding of the ‘Whistle Blowing’ procedures and are clear that they would report any allegation and incident of abuse to the Manager or a senior member of staff on duty. Service users felt that Halcyon Days is a safe home for resident to live in. The Deputy Manager reported and staff members confirmed that they have received training on the protection of vulnerable adults. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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 standard(s) 19 and 26. This establishment continues to provide good living conditions to its service users. EVIDENCE: Health and Safety Policies and procedures are in place and records seen provide evidence that service users and staff are offered the protection of reasonable safety measures. The communal areas and bedrooms are decorated and furnished in a style to reflect the period features of the building. The accommodation is bright and comfortable. The standard of decoration remains satisfactory. The furniture and fittings are of a good standard and bedrooms viewed are comfortable and residents appear to appreciate and enjoy their physical environment It is evident that the home and gardens are well maintained. A high standard of cleanliness was evident throughout those areas viewed. There were no mal-odours present. There are infection control policies and procedures in place. Suitable arrangements are made for the storage and collection of domestic and clinical waste. Risk assessment of the physical HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 16 environment is carried out as appropriate. There were no health and safety hazards noted. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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 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) 27,29 and 30. The levels and deployment of day and night staff at this establishment are satisfactory. The needs and requirements of the current resident group are being met in a holistic manner. The training needs of the staff team are being addressed and this ensures an improved level of service delivery for service users. EVIDENCE: Information gathered from staff duty rotas for a period of 4 weeks, discussion with staff including two members of the management team and service users provides evidence that the care staffing levels are adequate on both the day and night shifts. There are also sufficient ancillary members in dedicated roles for catering and housekeeping. The staff members on duty also reconciled with the rotas for the day. The home has robust Policies and procedures regarding recruitment, induction and training of staff members, and appears to put these into practice, which means that residents are in safe hands. The recruitment files for five new staff members were scrutinised and these reflected the documents required by the Care Homes Regulations. None of the files contained a recent photo of the members concerned. A requirement has been made on this issue. Evidence indicates that staff members have received all mandatory training to enable them to do their work competently. There are currently fifteen members of staff who are undertaking their NVQ Level 2 assessment, which is very positive. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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 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, 36 and 38 The management of this home remains satisfactory. Policies and procedures ensure that the health, safety and welfare of service users, and staff are safeguarded. EVIDENCE: The home has two registered Owner/Managers and they have been managing this home for over twenty-one years. Service users and staff have testified to their commitment and they have consistently managed this home very well. The Owner/Managers have proposed the Deputy Manager to become the registered Manager for this establishment. A completed application form is awaited from the Deputy Manager. The Deputy Manager has instituted a formal supervision system for all staff members. Staff members interviewed confirmed that they receive one to one supervision from the Deputy Manager. The Deputy Manager and Owner/Managers operate an open door policy and therefore, support and HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 19 informal supervision is available on an on-going basis – a view echoed and much appreciated by staff members spoken to. Health and safety issues are being attended to. Risk assessments are in place and updated regularly. The fire alarm system, hot water temperature and portable electrical appliances are checked as appropriate. A requirement has been made for the frequency of fire drills to be increased to once every three months. HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 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 x 3 3 x x x x 3 x 2 HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 21 Not applicable 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 29 38 Regulation 19 (1) (b) (i) 23 (4) Requirement Individual files for new recruits must contain a recent photograph. The frequency of fire drills must be increased to once every three months. Timescale for action 20.06.05 20.06.05 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 Good Practice Recommendations HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 22 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 HALCYON DAYS I52-I02 S19403 Halcyon Days v222187 200405 Stage 4.doc Version 1.20 Page 23 - 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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